DECEMBER 2013 VOLUME 11 ISSUE 4
DECEMBER 2013 VOLUME 11 ISSUE 4 pain news a publication of the british pain society PAIN NEWS
CYMBALTA® (DULOXETINE) ABBREVIATED PRESCRIBING increase in blood pressure. For patients who experience a sustained increase in failure, hepatitis, acute liver injury, angioneurotic oedema, Stevens-Johnson INFORMATION Presentation Hard gastro-resistant capsules, 30mg or 60mg of blood pressure while receiving duloxetine, consider either dose reduction or syndrome, trismus, and gynaecological haemorrhage have been made. Cases of duloxetine. Also contains sucrose. Uses Treatment of major depressive disorder. gradual discontinuation. Caution in patients taking anticoagulants or products suicidal ideation and suicidal behaviours have been reported during duloxetine Treatment of generalised anxiety disorder. Treatment of diabetic peripheral known to affect platelet function, and those with bleeding tendencies. therapy or early after treatment discontinuation. Cases of aggression and anger neuropathic pain (DPNP) in adults. Dosage and Administration Major Hyponatraemia has been reported rarely, predominantly in the elderly. Caution have been reported, particularly early in treatment or after treatment Depressive Disorder Starting and maintenance dose is 60mg once daily, with or is required in patients at increased risk for hyponatraemia, such as elderly, discontinuation. Cases of convulsion and tinnitus have been reported after without food. Dosages up to a maximum dose of 120mg per day have been cirrhotic, or dehydrated patients, or patients treated with diuretics. treatment discontinuation. Discontinuation of duloxetine (particularly abrupt) evaluated from a safety perspective in clinical trials. However, there is no clinical Hyponatraemia may be due to a syndrome of inappropriate anti-diuretic commonly leads to withdrawal symptoms. Dizziness, sensory disturbances evidence suggesting that patients not responding to the initial recommended hormone secretion (SIADH). Adverse reactions may be more common during (including paraesthesia), sleep disturbances (including insomnia and intense dose may benefit from dose up-titrations. Therapeutic response is usually seen concomitant use of Cymbalta and herbal preparations containing St John’s Wort. dreams), fatigue, agitation or anxiety, nausea and/or vomiting, tremor, headache, Fit for work team after 2-4 weeks. After establishing response, it is recommended to continue Monitor for suicidal thoughts, especially during first weeks of therapy, dose irritability, diarrhoea, hyperhydrosis, and vertigo are the most commonly treatment for several months, in order to avoid relapse. In patients responding changes, and in patients under 25 years old. Since treatment may be associated reported reactions. The heart rate-corrected QT interval in duloxetine-treated to duloxetine, and with a history of repeated episodes of major depression, with sedation and dizziness, patients should be cautioned about their ability to patients did not differ from that seen in placebo-treated patients. No clinically Return to work further long-term treatment at 60 to 120mg/day could be considered. Generalised drive a car or operate hazardous machinery. Cases of akathisia/psychomotor significant differences were observed for QT, PR, QRS, or QTcB measurements Anxiety Disorder The recommended starting dose in patients with generalised restlessness have been reported for duloxetine. Duloxetine is used under different between duloxetine-treated and placebo-treated patients. In clinical trials in anxiety disorder is 30mg once daily, with or without food. In patients with trademarks in several indications (major depressive disorder, generalised anxiety patients with DPNP, small but statistically significant increases in fasting blood Laughing the pain away insufficient response the dose should be increased to 60mg, which is the usual disorder, stress urinary incontinence, and diabetic neuropathic pain). The use of glucose were observed in duloxetine-treated patients compared to placebo at 12 maintenance dose in most patients. In patients with co-morbid major depressive more than one of these products concomitantly should be avoided. Cases of liver weeks. At 52 weeks there was a small increase in fasting blood glucose and in disorder, the starting and maintenance dose is 60mg once daily. Doses up to injury, including severe elevations of liver enzymes (>10-times upper limit of total cholesterol in duloxetine-treated patients compared with a slight decrease Why not a career in pain medicine 120mg per day have been shown to be efficacious and have been evaluated from normal), hepatitis, and jaundice have been reported with duloxetine. Most of in the routine care group. There was also an increase in HbA1c in both groups, a safety perspective in clinical trials. In patients with insufficient response to them occurred during the first months of treatment. Duloxetine should be used but the mean increase was 0.3% greater in the duloxetine-treated group. For full 60mg, escalation up to 90mg or 120mg may therefore be considered. After with caution in patients with substantial alcohol use or with other drugs details of these and other side-effects, please see the Summary of Product Changing the culture of pain management consolidation of the response, it is recommended to continue treatment for associated with hepatic injury. Capsules contain sucrose. Patients with rare Characteristics, which is available at http://www.medicines.org.uk/emc/. Overdose several months, in order to avoid relapse. Diabetic Peripheral Neuropathic Pain hereditary problems of fructose intolerance, glucose-galactose malabsorption, or Cases of overdoses, alone or in combination with other drugs, with duloxetine Starting and maintenance dose is 60mg daily, with or without food. Doses above sucrose-isomaltase insufficiency should not take this medicine. Interactions doses of 5400mg have been reported. Some fatalities have occurred, primarily 60mg/day, up to a maximum dose of 120mg/day in evenly divided doses, have Caution is advised when taken in combination with other centrally acting with mixed overdoses, but also with duloxetine alone at a dose of approximately been evaluated from a safety perspective. Some patients that respond medicinal products or substances, including alcohol and sedative medicinal 1000mg. Signs and symptoms of overdose (duloxetine alone or in combination insufficiently to 60mg may benefit from a higher dose. The medicinal response products; exercise caution when using in combination with antidepressants. In with other medicinal products) included somnolence, coma, serotonin should be evaluated after 2 months treatment. Additional response after this rare cases, serotonin syndrome has been reported in patients using SSRIs/SNRIs syndrome, seizures, vomiting, and tachycardia. Legal Category POM Marketing time is unlikely. The therapeutic benefit should regularly be reassessed. Abrupt concomitantly with serotonergic agents. Caution is advisable if duloxetine is Authorisation Numbers EU/1/04/296/001, EU/1/04/296/002 Basic NHS Cost discontinuation should be avoided. When stopping treatment with Cymbalta used concomitantly with serotonergic agents like SSRIs/SNRIs, tricyclics, MAOIs £22.40 per pack of 28 X 30mg capsules. £27.72 per pack of 28 X 60mg capsules. the dose should be gradually reduced over at least one to two weeks to reduce the like moclobemide and linezolid, St John’s Wort, antipsychotics, triptans, Date of Preparation or Last Review July 2013 Full Prescribing Information is risk of withdrawal reactions. If intolerable symptoms occur following a decrease tramadol, pethidine, and tryptophan. Undesirable effects may be more common Available From Eli Lilly and Company Limited, Lilly House, Priestley Road, in the dose or upon discontinuation of treatment, then resuming the previously during use with herbal preparations containing St John’s Wort. Effects on other Basingstoke, Hampshire, RG24 9NL Telephone: Basingstoke (01256) 315 000 prescribed dose may be considered. Subsequently, continue decreasing the dose, drugs: Caution is advised if co-administered with products that are E-mail: [email protected] Website: www.lillypro.co.uk CYMBALTA® but at a more gradual rate. Contra-indications Hypersensitivity to any of the predominantly metabolised by CYP2D6 (risperidone, tricyclic antidepressants (duloxetine) is a registered trademark of Eli Lilly and Company. components. Combination with MAOIs. Liver disease resulting in hepatic [TCAs], such as nortriptyline, amitriptyline, and imipramine) particularly if impairment. Use with potent inhibitors of CYP1A2, eg, fluvoxamine, they have a narrow therapeutic index (such as flecainide, propafenone, and UKCYM01679b July 2013 ciprofloxacin, enoxacin. Severe renal impairment (creatinine clearance <30ml/ metoprolol). Undesirable Effects The majority of common adverse reactions min). Should be used in pregnancy only if the potential benefit justifies the were mild to moderate, usually starting early in therapy, and most tended to References: potential risk to the foetus. Breast-feeding is not recommended. Initiation in subside as therapy continued. Those observed from spontaneous reporting and 1. Goldstein DJ, Lu Y, Detke MJ, et al. Duloxetine vs placebo in patients with patients with uncontrolled hypertension that could expose patients to a potential in placebo-controlled clinical trials in depression, generalised anxiety disorder, painful diabetic neuropathy. Pain 2005;116:109-18. risk of hypertensive crisis. Precautions Do not use in children and adolescents and diabetic neuropathic pain at a rate of ≥1/100, or where the event is clinically 2. Hall JA et al. Poster presented at the 25th American Pain Society Meeting; 2006; under the age of 18. No dosage adjustment is recommended for elderly patients relevant, are: Very common (≥1/10): Headache, somnolence, nausea, dry mouth. May 3-6; San Antonio, USA. solely on the basis of age. However, as with any medicine, caution should be Common (≥1/100 and <1/10): Weight decrease, palpitations, dizziness, lethargy, 3. Lilly. Cymbalta [EU] Summary of Product Characteristics, July 2013. exercised. Data on the use of Cymbalta in elderly patients with generalised tremor, paraesthesia, blurred vision, tinnitus, yawning, constipation, diarrhoea, 4. British Pain Society, Pain Assessment and Management Pathways: Neuropathic anxiety disorder are limited. Use with caution in patients with a history of abdominal pain, vomiting, dyspepsia, flatulence, sweating increased, rash, Pain. Available at http://bps.mapofmedicine.com/evidence/bps/index.html mania, bipolar disorder, or seizures. As with other serotonergic agents, serotonin musculoskeletal pain, muscle spasm, dysuria, urinary frequency, ejaculation Acccessed 6/6/13 syndrome, a potentially life-threatening condition, may occur with duloxetine disorder, ejaculation delayed, decreased appetite, blood pressure increased, treatment, particularly with concomitant use of other serotonergic agents, as flushing, falls, fatigue, erectile dysfunction, insomnia, agitation, libido decreased, described under ‘Interactions’ (below). Caution in patients with increased intra- anxiety, orgasm abnormal, abnormal dreams. Clinical trial and spontaneous ocular pressure or those at risk of acute narrow-angle glaucoma. Duloxetine has reports of anaphylactic reaction, hyperglycaemia (reported especially in diabetic Adverse events should be reported. Reporting forms and been associated with an increase in blood pressure and clinically significant patients), mania, hyponatraemia, SIADH, hallucinations, dyskinesia, serotonin further information can be found at: hypertension in some patients. In patients with known hypertension and/or syndrome, extra-pyramidal symptoms, convulsions, akathisia, psychomotor www.mhra.gov.uk/yellowcard. other cardiac disease, blood pressure monitoring is recommended as appropriate, restlessness, glaucoma, mydriasis, syncope, tachycardia, supra-ventricular Adverse events and product complaints should also be especially during the first month of treatment. Use with caution in patients arrhythmia (mainly atrial fibrillation), hypertension, hypertensive crisis, whose conditions could be compromised by an increased heart rate or by an epistaxis, gastritis, haematochezia, gastro-intestinal haemorrhage, hepatic reported to Lilly: please call Lilly UK on 01256 315 000.
ISSN 2050–4497
PAN_cover_sagepub.indd 1 14/11/2013 8:48:56 PM PAN_cover_sagepub.indd 2 14/11/2013 8:48:56 PM PAN_cover_sagepub.indd 2 08/11/2013 4:51:03 PM CYMBALTA® (DULOXETINE) ABBREVIATED PRESCRIBING increase in blood pressure. For patients who experience a sustained increase in failure, hepatitis, acute liver injury, angioneurotic oedema, Stevens-Johnson INFORMATION Presentation Hard gastro-resistant capsules, 30mg or 60mg of blood pressure while receiving duloxetine, consider either dose reduction or syndrome, trismus, and gynaecological haemorrhage have been made. Cases of duloxetine. Also contains sucrose. Uses Treatment of major depressive disorder. gradual discontinuation. Caution in patients taking anticoagulants or products suicidal ideation and suicidal behaviours have been reported during duloxetine Treatment of generalised anxiety disorder. Treatment of diabetic peripheral known to affect platelet function, and those with bleeding tendencies. therapy or early after treatment discontinuation. Cases of aggression and anger neuropathic pain (DPNP) in adults. Dosage and Administration Major Hyponatraemia has been reported rarely, predominantly in the elderly. Caution have been reported, particularly early in treatment or after treatment Depressive Disorder Starting and maintenance dose is 60mg once daily, with or is required in patients at increased risk for hyponatraemia, such as elderly, discontinuation. Cases of convulsion and tinnitus have been reported after without food. Dosages up to a maximum dose of 120mg per day have been cirrhotic, or dehydrated patients, or patients treated with diuretics. treatment discontinuation. Discontinuation of duloxetine (particularly abrupt) evaluated from a safety perspective in clinical trials. However, there is no clinical Hyponatraemia may be due to a syndrome of inappropriate anti-diuretic commonly leads to withdrawal symptoms. Dizziness, sensory disturbances evidence suggesting that patients not responding to the initial recommended hormone secretion (SIADH). Adverse reactions may be more common during (including paraesthesia), sleep disturbances (including insomnia and intense dose may benefit from dose up-titrations. Therapeutic response is usually seen concomitant use of Cymbalta and herbal preparations containing St John’s Wort. dreams), fatigue, agitation or anxiety, nausea and/or vomiting, tremor, headache, after 2-4 weeks. After establishing response, it is recommended to continue Monitor for suicidal thoughts, especially during first weeks of therapy, dose irritability, diarrhoea, hyperhydrosis, and vertigo are the most commonly treatment for several months, in order to avoid relapse. In patients responding changes, and in patients under 25 years old. Since treatment may be associated reported reactions. The heart rate-corrected QT interval in duloxetine-treated to duloxetine, and with a history of repeated episodes of major depression, with sedation and dizziness, patients should be cautioned about their ability to patients did not differ from that seen in placebo-treated patients. No clinically further long-term treatment at 60 to 120mg/day could be considered. Generalised drive a car or operate hazardous machinery. Cases of akathisia/psychomotor significant differences were observed for QT, PR, QRS, or QTcB measurements Anxiety Disorder The recommended starting dose in patients with generalised restlessness have been reported for duloxetine. Duloxetine is used under different between duloxetine-treated and placebo-treated patients. In clinical trials in anxiety disorder is 30mg once daily, with or without food. In patients with trademarks in several indications (major depressive disorder, generalised anxiety patients with DPNP, small but statistically significant increases in fasting blood insufficient response the dose should be increased to 60mg, which is the usual disorder, stress urinary incontinence, and diabetic neuropathic pain). The use of glucose were observed in duloxetine-treated patients compared to placebo at 12 maintenance dose in most patients. In patients with co-morbid major depressive more than one of these products concomitantly should be avoided. Cases of liver weeks. At 52 weeks there was a small increase in fasting blood glucose and in disorder, the starting and maintenance dose is 60mg once daily. Doses up to injury, including severe elevations of liver enzymes (>10-times upper limit of total cholesterol in duloxetine-treated patients compared with a slight decrease
120mg per day have been shown to be efficacious and have been evaluated from normal), hepatitis, and jaundice have been reported with duloxetine. Most of in the routine care group. There was also an increase in HbA1c in both groups, a safety perspective in clinical trials. In patients with insufficient response to them occurred during the first months of treatment. Duloxetine should be used but the mean increase was 0.3% greater in the duloxetine-treated group. For full 60mg, escalation up to 90mg or 120mg may therefore be considered. After with caution in patients with substantial alcohol use or with other drugs details of these and other side-effects, please see the Summary of Product consolidation of the response, it is recommended to continue treatment for associated with hepatic injury. Capsules contain sucrose. Patients with rare Characteristics, which is available at http://www.medicines.org.uk/emc/. Overdose several months, in order to avoid relapse. Diabetic Peripheral Neuropathic Pain hereditary problems of fructose intolerance, glucose-galactose malabsorption, or Cases of overdoses, alone or in combination with other drugs, with duloxetine Starting and maintenance dose is 60mg daily, with or without food. Doses above sucrose-isomaltase insufficiency should not take this medicine. Interactions doses of 5400mg have been reported. Some fatalities have occurred, primarily 60mg/day, up to a maximum dose of 120mg/day in evenly divided doses, have Caution is advised when taken in combination with other centrally acting with mixed overdoses, but also with duloxetine alone at a dose of approximately been evaluated from a safety perspective. Some patients that respond medicinal products or substances, including alcohol and sedative medicinal 1000mg. Signs and symptoms of overdose (duloxetine alone or in combination insufficiently to 60mg may benefit from a higher dose. The medicinal response products; exercise caution when using in combination with antidepressants. In with other medicinal products) included somnolence, coma, serotonin should be evaluated after 2 months treatment. Additional response after this rare cases, serotonin syndrome has been reported in patients using SSRIs/SNRIs syndrome, seizures, vomiting, and tachycardia. Legal Category POM Marketing time is unlikely. The therapeutic benefit should regularly be reassessed. Abrupt concomitantly with serotonergic agents. Caution is advisable if duloxetine is Authorisation Numbers EU/1/04/296/001, EU/1/04/296/002 Basic NHS Cost discontinuation should be avoided. When stopping treatment with Cymbalta used concomitantly with serotonergic agents like SSRIs/SNRIs, tricyclics, MAOIs £22.40 per pack of 28 X 30mg capsules. £27.72 per pack of 28 X 60mg capsules. the dose should be gradually reduced over at least one to two weeks to reduce the like moclobemide and linezolid, St John’s Wort, antipsychotics, triptans, Date of Preparation or Last Review July 2013 Full Prescribing Information is risk of withdrawal reactions. If intolerable symptoms occur following a decrease tramadol, pethidine, and tryptophan. Undesirable effects may be more common Available From Eli Lilly and Company Limited, Lilly House, Priestley Road, in the dose or upon discontinuation of treatment, then resuming the previously during use with herbal preparations containing St John’s Wort. Effects on other Basingstoke, Hampshire, RG24 9NL Telephone: Basingstoke (01256) 315 000 prescribed dose may be considered. Subsequently, continue decreasing the dose, drugs: Caution is advised if co-administered with products that are E-mail: [email protected] Website: www.lillypro.co.uk CYMBALTA® but at a more gradual rate. Contra-indications Hypersensitivity to any of the predominantly metabolised by CYP2D6 (risperidone, tricyclic antidepressants (duloxetine) is a registered trademark of Eli Lilly and Company. components. Combination with MAOIs. Liver disease resulting in hepatic [TCAs], such as nortriptyline, amitriptyline, and imipramine) particularly if impairment. Use with potent inhibitors of CYP1A2, eg, fluvoxamine, they have a narrow therapeutic index (such as flecainide, propafenone, and UKCYM01679b July 2013 ciprofloxacin, enoxacin. Severe renal impairment (creatinine clearance <30ml/ metoprolol). Undesirable Effects The majority of common adverse reactions min). Should be used in pregnancy only if the potential benefit justifies the were mild to moderate, usually starting early in therapy, and most tended to References: potential risk to the foetus. Breast-feeding is not recommended. Initiation in subside as therapy continued. Those observed from spontaneous reporting and 1. Goldstein DJ, Lu Y, Detke MJ, et al. Duloxetine vs placebo in patients with patients with uncontrolled hypertension that could expose patients to a potential in placebo-controlled clinical trials in depression, generalised anxiety disorder, painful diabetic neuropathy. Pain 2005;116:109-18. risk of hypertensive crisis. Precautions Do not use in children and adolescents and diabetic neuropathic pain at a rate of ≥1/100, or where the event is clinically 2. Hall JA et al. Poster presented at the 25th American Pain Society Meeting; 2006; under the age of 18. No dosage adjustment is recommended for elderly patients relevant, are: Very common (≥1/10): Headache, somnolence, nausea, dry mouth. May 3-6; San Antonio, USA. solely on the basis of age. However, as with any medicine, caution should be Common (≥1/100 and <1/10): Weight decrease, palpitations, dizziness, lethargy, 3. Lilly. Cymbalta [EU] Summary of Product Characteristics, July 2013. exercised. Data on the use of Cymbalta in elderly patients with generalised tremor, paraesthesia, blurred vision, tinnitus, yawning, constipation, diarrhoea, 4. British Pain Society, Pain Assessment and Management Pathways: Neuropathic anxiety disorder are limited. Use with caution in patients with a history of abdominal pain, vomiting, dyspepsia, flatulence, sweating increased, rash, Pain. Available at http://bps.mapofmedicine.com/evidence/bps/index.html mania, bipolar disorder, or seizures. As with other serotonergic agents, serotonin musculoskeletal pain, muscle spasm, dysuria, urinary frequency, ejaculation Acccessed 6/6/13 syndrome, a potentially life-threatening condition, may occur with duloxetine disorder, ejaculation delayed, decreased appetite, blood pressure increased, treatment, particularly with concomitant use of other serotonergic agents, as flushing, falls, fatigue, erectile dysfunction, insomnia, agitation, libido decreased, described under ‘Interactions’ (below). Caution in patients with increased intra- anxiety, orgasm abnormal, abnormal dreams. Clinical trial and spontaneous ocular pressure or those at risk of acute narrow-angle glaucoma. Duloxetine has reports of anaphylactic reaction, hyperglycaemia (reported especially in diabetic Adverse events should be reported. Reporting forms and been associated with an increase in blood pressure and clinically significant patients), mania, hyponatraemia, SIADH, hallucinations, dyskinesia, serotonin further information can be found at: hypertension in some patients. In patients with known hypertension and/or syndrome, extra-pyramidal symptoms, convulsions, akathisia, psychomotor www.mhra.gov.uk/yellowcard. other cardiac disease, blood pressure monitoring is recommended as appropriate, restlessness, glaucoma, mydriasis, syncope, tachycardia, supra-ventricular Adverse events and product complaints should also be especially during the first month of treatment. Use with caution in patients arrhythmia (mainly atrial fibrillation), hypertension, hypertensive crisis, whose conditions could be compromised by an increased heart rate or by an epistaxis, gastritis, haematochezia, gastro-intestinal haemorrhage, hepatic reported to Lilly: please call Lilly UK on 01256 315 000. Third Floor Churchill House 35 Red Lion Square London WC1R 4SG United Kingdom Tel: +44 (0)20 7269 7840 Fax: +44 (0)20 7831 0859 Email [email protected] www.britishpainsociety.org
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PAN11410.1177/2050449713510821Can we change the culture of pain management?Can we change the culture of pain management? 5108212013 Officers Dr Kate Grady Representative: Faculty of Pain Medicine Regulars Regulars Can we change the culture of Pain News Dr William Campbell 11(4) 208 –211 203 Editorial pain management? © The British Pain Society 2013 President Dr Austin Leach Media, NICE, PLC Liaison 205 From the President Dr John D Loeser Dr John D Loeser is Professor Emeritus of Neurological Surgery and Anesthesiology and Pain Medicine and was the Director of the Multidisciplinary Pain Centre at the University of Washington from 1983 to 1997. He is the Past 207 From the Honorary Secretary President of the American Pain Society and the International Association for the Study of Pain. He was the Assistant Dr John Goddard Dean for Curriculum at the University of Washington from 1977 to 1982. He is the editor of Bonica’s ‘The Management of Pain’ and has lectured and written extensively on both research and clinical aspects of pain. The following is a Prof. Gary Macfarlane transcript of his main lecture at the Philosophy and Ethics SIG meeting at Launde Abbey, June 2013. Vice President 208 Can we change the culture of pain There are at least 10 Pain Societies in the conceptual models. There are many Chair, Scientific Programme Committee management? United States, many with state- or physicians who are fixated on a region-based chapters. Each one biomedical model of disease and just promulgates guidelines, has meetings to cannot conceive of the issue that present their products and often something outside of a patient’s back Prof. Richard Langford threatens litigation against people who may be responsible for their pain Dr Andrew Nicolaou say or do things that threaten their behaviour. Everybody knows the highly interests. You can tell what a pain mechanistic Descartes model of the specialist does for a living from the body and the fire. That was a pretty good Immediate Past President organisation he or she belongs to. I’m model for its time, but the Melzack and Chair, Implementation and Dissemination sure in the United Kingdom, you have Wall Gate hypothesis in 1965 totally something similar. I am aware of the revolutionised the way physicians revolution you had in the Pain Society thought about pain and was a seminal News because of the President’s agreement to act in leading to the development of a Working Group standards of care that did not meet the pain world. Dr Andrew Baranowski desires of many of its members. If you Second, we lack outcomes data. You look at the guidelines, you can are lucky if you can find data for a few immediately tell who wrote them, and too months, but a year’s follow-up, which is 212 Update from Acute Pain SIG – chest(er) The United States and the United many patients get what the provider reasonable for a chronic pain patient, is Kingdom have very different health-care does irrespective of what the patient ridiculously rare. Without outcome data, Honorary Treasurer Dr Ann Taylor systems. Many of the issues that I will needs. There are pain clinics in the you don’t have feedback on what your pain address may be more prominent and United States where 100% of the interventions do; so, you keep doing the problematic in my country than in yours. patients get an injection or a surgical wrong thing over and over again. But my travels have told me that the procedure without a history taken or a Meaningful outcomes data must involve Project Facilitator - Problematic Pain same issues come up in every country I physical examination. Part of the chaos follow-up of at least 6 months to a year have been in; it’s just the relative and lack of a common culture in our or even longer, and include self-reported Dr Martin Johnson 214 PMP SIG - rehabilitation: proportion of which issue is the big one country is that there is no standard of pain, functional improvement and health- that changes. what should be done before surgery or care utilisation, especially with regard to treatment is implemented. We have medication, work status and quality-of- Prof. Irene Tracey moving forward with confidence different organisations promulgating life assessment. Honorary Secretary Culture directly opposing the guidelines and In the United States, physicians are Is there a culture of pain management? each provider (mainly private insurers) pressured by the need to fund their Or are there several cultures? Or is it just deciding what they are going to pay for. practice or the institution in which they 217 e-Learning in pain chaos with no culture behind it where So, why the chaos? The first problem practice to work in unsatisfactory ways. Representative: IASP They are pushed into seeing more everybody has their own viewpoint? is that many people have wrong 218 Pain relief in Uganda 208 Pain News l December 2013 Vol 11 No 4 Elected Dr Thanthullu Vasu 221 Updates from Pain in Developing PAN510821.indd 208 28/10/2013 7:17:51 PM
PAN11410.1177/2050449713511367NewsNorthern Ireland pain commissioning meeting Mr Neil Berry Editor, Pain News Countries SIG: Essential Pain Management 5113672013
Dr Heather Cameron 222 Northern Ireland Pain Commissioning News Meeting Northern Ireland Pain Commissioning Pain News Mr Paul Cameron 11(4) 222 –223 Secretariat Meeting © The British Pain Society 2013 Dr Sam Eldabe 223 BPS responses to National Institute for Jenny Nicholas Health and Care Excellence (NICE) Dr Pamela F Bell Chair, The Pain Alliance of Northern Ireland Dr Oliver Hart Secretariat Manager On 10 September, health-care 224 BSR campaign professionals, carers and patients from all regions of Northern Ireland gathered Dr Tim Johnson for a Pain Commissioning Meeting at Riddel Hall. The event was a joint venture of the British and Northern Ireland Pain Ken Obbard Societies, the Long Term Conditions Prof. Roger Knaggs Alliance Northern Ireland (LTCANI), the Patient and Client Council (PCC), the Northern Ireland Confederation of Health Events & Membership Officer and Social Care Organisations (NICON) Commissioning meeting speakers From left Happy panellists From left to right: Mrs and the Pain Alliance of Northern Ireland to right: Dr William Campbell; Dr Pamela Bell; Louise Skelly, Director of Operations, Patient Dr Rajesh Munglani Professional perspectives (PANI), working in partnership with the Mrs Sarah Muckle, Consultant in Public and Client Council; Dr Pamela Bell, Chair, Pain Therapy Group of the Association of Health, Kirklees; and Dr Martin Johnson. Pain Alliance of Northern Ireland; and the British Pharmaceutical Industry, Dr William Campbell, President BPS. Northern Ireland, who provided financial services that are accessible and Dr Mick Serpell Dina Almuli aid and logistical support. appropriate to their needs. This survey and when assessed against the World 225 Rayen’s column – Do fish feel pain? The meeting opened with a has gathered an immense amount of Health Organization (WHO) model of presentation of the preliminary results of data. This first publication goes to the health has demonstrated its the survey of patient experience of pain PCC Board for approval on 15 October; effectiveness. There are many lessons for Events & Marketing Officer and pain services (both primary and further analysis of the data by region of Northern Ireland arising from this and 227 From Pain to Prospects? – helping secondary care) carried out by the PCC. domicile, age, gender and diagnosis is much discussion ensued – particularly ‘The Painful Truth: 2,500 Patients Tell planned. around the use of health trainers as part their Story’ makes difficult reading for Delegates then heard from Sarah of the early intervention strategy. those who practice in this field, but really Muckle, Consultant in Public Health, Dr William Campbell introduced the people on welfare benefits with chronic holds no surprises. Patients report that Kirklees, about the approach that they Map of Medicine and the British Pain Co-Opted Members they often feel ignored, disbelieved and had adopted to transform services to Society’s role in developing the Pathways patronised by health-care professionals. those who suffer long-term pain. The of Pain. Dr Martin Johnson elaborated on pain Many wait years to get a firm diagnosis basis of their work was a joint strategic these as he demonstrated how they of the cause of their pain, and feel needs assessment to identify those most could be used to inform commissioning Prof. Sam Ahmedzai dissatisfied with the care that they vulnerable to the effects of long-term of pain services at both primary and receive. The impact of the pain on their pain. They worked closely with their secondary care level. 231 Service evaluation – adequacy of work, social and family lives is clear, as is population and developed a range of The afternoon finished with round table their frustration with the lack of strategies to support patients in self- discussions to determine the actions that Representative: Association for Palliative signposting or referral to appropriate management of their pain and provided delegates wished to be taken to most services. They would like to see education to general practitioner (GPs) improve pains services. Of these, the aseptic techniques in pain clinic–based education and training in pain and other health-care professionals, three deemed most important for management for all health-care particularly in primary care and immediate action were education for GPs Medicine professionals enhanced, better support community settings, to ensure that the and health-care professionals at every procedures to allow them to manage their condition services were sustainable. Their strategy level of the system, health-care funding and a coherent strategy for delivery of has been effective in early intervention to be identified for Condition Prof. Nick Allcock 235 Quality-of-life improvements after spinal cord stimulator insertion for chronic pain 222 Pain News l December 2013 Vol 11 No 4
Chair, Communications Committee PAN511367.indd 222 29/10/2013 3:59:53 PM Mr Antony Chuter Informing practice Lumbar epidural adhesiolysis by Racz catheter technique
Chair, Patient Liaison Committee Informing practice Procedure They are then encouraged to move Figure 2. The X-rays shows a filling All procedures are performed in the freely and to stretch the limbs, and flex and defect. One can also see a vascular operating room, under appropriate extend the spine, and if possible attend for runoff of contrast aseptic conditions, using fluoroscopy. physiotherapy, hoping to further stretch We established intravenous access, and break down epidural adhesions. Dr Beverly Collett 239 Waiting times for access to a UK giving conscious sedation as required. We applied local anaesthetic to the Our results caudal injection site. The epidural space multidisciplinary chronic pain service was accessed via caudal route (sacral Graph 1. Age distribution Representative: CPPC hiatus) using a specially designed 16G RX Coudé epidural needle (Epimed) under fluoroscopic guidance. Lumbar 242 Does the South Devon Pain epidurogram was carried out using 2–5 mL of iohexol contrast-medium (Omnipaque-240), with adhesions Ms Felicia Cox identified as filling defects along course Management Services meet the needs of nerve roots. Additionally, absence of intravascular, subarachnoid and subdural spread of contrast was Editor, British Journal of Pain and of patients who report return to work/ confirmed. Figure 3. Post-adhesiolysis contrast The Racz catheter, a spring-guided spread outlining of S1 nerve root reinforced catheter, is passed through 15 men and 8 women were treated the Coudé needle to the site of filling with percutaneous lumbar epidural Representative, RCN retention in work difficulties? defect or the site of patient’s pathology adhesiolysis (PLEA); as determined by the dermatomal level Age distribution is shown in (Graph 1); of the patient’s symptoms, and by investigation (MRI) findings (Figure 1). 23 patients had 27 procedures; 251 Why not a career in Pain Medicine? Following placement of the catheter, 20 of 23 patients had previous mechanical adhesiolysis is carried out Prof. Maria Fitzgerald surgical spinal decompression. by movement of the catheter, and by injecting small aliquots of 0.9% saline 253 Dealing with DNAs with or without hyaluronidase. Graph 2. Duration and quality of Representative: Science Following adhesiolysis, a repeat pain reduction epidurogram is carried out, successful
255 Lumbar epidural adhesiolysis by Racz adhesiolysis being confirmed by the Figure 1. Racz catheter in the spread of contrast material along the sacral epidural space nerve root (Figures 2 and 3), with filling in catheter technique of the ventro-lateral epidural space. In all, 3–6 mL of mixture of 1% lidocaine with triamcinolone 40 mg is delivered at the The editor welcomes contributions target area. Of the 27 procedures performed, PAIN NEWS is published quarterly. 259 The effect of capsaicin 8% patch in Following completion of the procedure, 20 procedures (74%) were beneficial; needle and catheter are removed, and a bio-occlusive dressing is placed. The 44.4% of the patients had > 50% including letters, short clinical reports and catheter is checked for any damage and reduction in pain (Graph 2); Circulation 1600. For information on patients with peripheral neuropathic pain for intactness. 74% patients had some benefit (pain Patients are observed in the recovery reduction), while in nearly 60% room, and discharged home when patients, the benefit lasted from news of interest to members, including following surgery recovered, with appropriate aftercare 2 to 5 months (Graph 2). advertising please contact instructions and contact information. Kasia Pienaar, SAGE Publications, notice of meetings. 262 Assessment of outcomes after December 2013 Vol 11 No 4 l Pain News 257 Next submission deadline : interventions – the Glasgow story 1 Oliver’s Yard, 55 City Road, PAN511369.indd 257 29/10/2013 4:14:03 PM
PAN11410.1177/2050449713507397Pain NewsRayen London EC1Y 1SP, UK. 10th January 2014 5073972013 Tel: +44 (0)20 7324 8601; End stuff Book reviews Laughing the pain away Material should be sent to: Pain News 11(4) 265 –265 Email: [email protected] © The British Pain Society 2013 266 Oxford American Pain Library: Shruthi Rayen King Edward VI High School for Girls, Birmingham Dr Thanthullu Vasu [email protected] DECEMBER 2013 VOLUME 11 ISSUE 4 Perioperative Pain Management by PAIN NEWS Editor When you bang your toe on the leg of a your immune system by table, what do you do? Cry out in lowering stress hormones agony? Whimper and let tears of self-pity and increasing the DECEMBER 2013 VOLUME 11 ISSUE 4 Richard D Urman, Nalini Vadivelu roll down your cheeks? Shout out a production of antibodies pain news The British Pain Society string of obscene vocabulary you hope and immune cells. your kids don’t hear? Or silently screw Laughter also protects a publication of the british pain society up your face and hop around in a the heart through the spontaneous albeit strange dance? increased blood flow, Third Floor Churchill House Whether you’re a hopper, a crier or which advances the sufferer in silence, some of you may be in function of blood vessels; a completely different and peculiar this can save you from category altogether - the laughers. Those many heart problems in 35 Red Lion Square strange people who are in fits of the future. End stuff hysterics when they’re in pain and you Another form of this stand there not knowing whether to help therapy is laughter yoga, them, laugh with them, or laugh at them. or Hasya yoga, which was started in because as far back as the 13th century, London WC1R 4SG United Kingdom However, there may be some method 1995 by an Indian doctor named Madan doctors used humour as a diversion for to their hilarious madness. Research has Kataria. However, this doesn’t involve their patients to reduce pain. Even 265 Laughing the pain away shown that laughter generates the release your conventional downward-dogs and further back than that, in the Book of of endorphins – the body’s own painkiller. sun salutations. It uses whimsical Proverbs, written over two thousand It is thought that the long sequence of activities and conducted breathing years ago, states the healing influences PAIN NEWS Email [email protected] exhalations that goes hand in hand with exercises to generate laughter. Moreover, of laughter. 267 Course Review: Practical Management genuine laughter contracts and relaxes doing this in a group would be even So, the next time you hit your thumb the abdominal muscles, therefore more beneficial, because as we all know, with a hammer, don’t wake the triggering a release of endorphins. laughter is as contagious as the common neighborhood with your cries to deities CYMBALTA® (DULOXETINE) ABBREVIATED PRESCRIBING increase in blood pressure. For patients who experience a sustained increase in failure, hepatitis, acute liver injury, angioneurotic oedema, Stevens-Johnson INFORMATION Presentation Hard gastro-resistant capsules, 30mg or 60mg of blood pressure while receiving duloxetine, consider either dose reduction or syndrome, trismus, and gynaecological haemorrhage have been made. Cases of duloxetine. Also contains sucrose. Uses Treatment of major depressive disorder. gradual discontinuation. Caution in patients taking anticoagulants or products suicidal ideation and suicidal behaviours have been reported during duloxetine The benefits don’t end there! A good cold. So, turning a shy giggle into a and hurriedly rummage for a Treatment of generalised anxiety disorder. Treatment of diabetic peripheral known to affect platelet function, and those with bleeding tendencies. therapy or early after treatment discontinuation. Cases of aggression and anger of Chronic Pain, Liverpool neuropathic pain (DPNP) in adults. Dosage and Administration Major Hyponatraemia has been reported rarely, predominantly in the elderly. Caution have been reported, particularly early in treatment or after treatment ISSN 2050-4497 (Print) chuckle alleviates physical tension, raging howl is far from impossible. paracetamol, simply find humour in the Depressive Disorder Starting and maintenance dose is 60mg once daily, with or is required in patients at increased risk for hyponatraemia, such as elderly, discontinuation. Cases of convulsion and tinnitus have been reported after without food. Dosages up to a maximum dose of 120mg per day have been cirrhotic, or dehydrated patients, or patients treated with diuretics. treatment discontinuation. Discontinuation of duloxetine (particularly abrupt) evaluated from a safety perspective in clinical trials. However, there is no clinical Hyponatraemia may be due to a syndrome of inappropriate anti-diuretic commonly leads to withdrawal symptoms. Dizziness, sensory disturbances keeping your muscles relaxed for up to Laughter as a pain relief is not as situation and let those trusty endorphins evidence suggesting that patients not responding to the initial recommended hormone secretion (SIADH). Adverse reactions may be more common during (including paraesthesia), sleep disturbances (including insomnia and intense dose may benefit from dose up-titrations. Therapeutic response is usually seen concomitant use of Cymbalta and herbal preparations containing St John’s Wort. dreams), fatigue, agitation or anxiety, nausea and/or vomiting, tremor, headache, Fit for work team after 2-4 weeks. After establishing response, it is recommended to continue Monitor for suicidal thoughts, especially during first weeks of therapy, dose irritability, diarrhoea, hyperhydrosis, and vertigo are the most commonly 45 minutes after. Similarly, it improves relatively modern as you may think, do the rest of the work! treatment for several months, in order to avoid relapse. In patients responding changes, and in patients under 25 years old. Since treatment may be associated reported reactions. The heart rate-corrected QT interval in duloxetine-treated to duloxetine, and with a history of repeated episodes of major depression, with sedation and dizziness, patients should be cautioned about their ability to patients did not differ from that seen in placebo-treated patients. No clinically Return to work further long-term treatment at 60 to 120mg/day could be considered. Generalised drive a car or operate hazardous machinery. Cases of akathisia/psychomotor significant differences were observed for QT, PR, QRS, or QTcB measurements ISSN 2050-4500 (Online) 268 A question of mind over matter: Anxiety Disorder The recommended starting dose in patients with generalised restlessness have been reported for duloxetine. Duloxetine is used under different between duloxetine-treated and placebo-treated patients. In clinical trials in anxiety disorder is 30mg once daily, with or without food. In patients with trademarks in several indications (major depressive disorder, generalised anxiety patients with DPNP, small but statistically significant increases in fasting blood Laughing the pain away insufficient response the dose should be increased to 60mg, which is the usual disorder, stress urinary incontinence, and diabetic neuropathic pain). The use of glucose were observed in duloxetine-treated patients compared to placebo at 12 maintenance dose in most patients. In patients with co-morbid major depressive more than one of these products concomitantly should be avoided. Cases of liver weeks. At 52 weeks there was a small increase in fasting blood glucose and in disorder, the starting and maintenance dose is 60mg once daily. Doses up to injury, including severe elevations of liver enzymes (>10-times upper limit of total cholesterol in duloxetine-treated patients compared with a slight decrease Why not career in pain medicine 120mg per day have been shown to be efficacious and have been evaluated from normal), hepatitis, and jaundice have been reported with duloxetine. Most of in the routine care group. There was also an increase in HbA1c in both groups, a safety perspective in clinical trials. In patients with insufficient response to them occurred during the first months of treatment. Duloxetine should be used but the mean increase was 0.3% greater in the duloxetine-treated group. For full 60mg, escalation up to 90mg or 120mg may therefore be considered. After with caution in patients with substantial alcohol use or with other drugs details of these and other side-effects, please see the Summary of Product Changing the culture of pain management consolidation of the response, it is recommended to continue treatment for associated with hepatic injury. Capsules contain sucrose. Patients with rare Characteristics, which is available at http://www.medicines.org.uk/emc/. Overdose Printed by Page Bros., Norwich, UK exploring the link between pain several months, in order to avoid relapse. Diabetic Peripheral Neuropathic Pain hereditary problems of fructose intolerance, glucose-galactose malabsorption, or Cases of overdoses, alone or in combination with other drugs, with duloxetine Starting and maintenance dose is 60mg daily, with or without food. Doses above sucrose-isomaltase insufficiency should not take this medicine. Interactions doses of 5400mg have been reported. Some fatalities have occurred, primarily 60mg/day, up to a maximum dose of 120mg/day in evenly divided doses, have Caution is advised when taken in combination with other centrally acting with mixed overdoses, but also with duloxetine alone at a dose of approximately been evaluated from a safety perspective. Some patients that respond medicinal products or substances, including alcohol and sedative medicinal 1000mg. Signs and symptoms of overdose (duloxetine alone or in combination insufficiently to 60mg may benefit from a higher dose. The medicinal response products; exercise caution when using in combination with antidepressants. In with other medicinal products) included somnolence, coma, serotonin should be evaluated after 2 months treatment. Additional response after this rare cases, serotonin syndrome has been reported in patients using SSRIs/SNRIs syndrome, seizures, vomiting, and tachycardia. Legal Category POM Marketing time is unlikely. The therapeutic benefit should regularly be reassessed. Abrupt concomitantly with serotonergic agents. Caution is advisable if duloxetine is Authorisation Numbers EU/1/04/296/001, EU/1/04/296/002 Basic NHS Cost discontinuation should be avoided. When stopping treatment with Cymbalta used concomitantly with serotonergic agents like SSRIs/SNRIs, tricyclics, MAOIs £22.40 per pack of 28 X 30mg capsules. £27.72 per pack of 28 X 60mg capsules. the dose should be gradually reduced over at least one to two weeks to reduce the like moclobemide and linezolid, St John’s Wort, antipsychotics, triptans, Date of Preparation or Last Review July 2013 Full Prescribing Information is perception, duration and disability risk of withdrawal reactions. If intolerable symptoms occur following a decrease tramadol, pethidine, and tryptophan. Undesirable effects may be more common Available From Eli Lilly and Company Limited, Lilly House, Priestley Road, in the dose or upon discontinuation of treatment, then resuming the previously during use with herbal preparations containing St John’s Wort. Effects on other Basingstoke, Hampshire, RG24 9NL Telephone: Basingstoke (01256) 315 000 prescribed dose may be considered. Subsequently, continue decreasing the dose, drugs: Caution is advised if co-administered with products that are E-mail: [email protected] Website: www.lillypro.co.uk CYMBALTA® but at a more gradual rate. Contra-indications Hypersensitivity to any of the predominantly metabolised by CYP2D6 (risperidone, tricyclic antidepressants (duloxetine) is a registered trademark of Eli Lilly and Company. components. Combination with MAOIs. Liver disease resulting in hepatic [TCAs], such as nortriptyline, amitriptyline, and imipramine) particularly if impairment. Use with potent inhibitors of CYP1A2, eg, fluvoxamine, they have a narrow therapeutic index (such as flecainide, propafenone, and UKCYM01679b July 2013 ciprofloxacin, enoxacin. Severe renal impairment (creatinine clearance <30ml/ metoprolol). Undesirable Effects The majority of common adverse reactions min). Should be used in pregnancy only if the potential benefit justifies the were mild to moderate, usually starting early in therapy, and most tended to References: potential risk to the foetus. Breast-feeding is not recommended. Initiation in subside as therapy continued. Those observed from spontaneous reporting and 1. Goldstein DJ, Lu Y, Detke MJ, et al. Duloxetine vs placebo in patients with patients with uncontrolled hypertension that could expose patients to a potential in placebo-controlled clinical trials in depression, generalised anxiety disorder, painful diabetic neuropathy. Pain 2005;116:109-18. 272 Remifentanil PCA in acute sickle crisis risk of hypertensive crisis. Precautions Do not use in children and adolescents and diabetic neuropathic pain at a rate of ≥1/100, or where the event is clinically 2. Hall JA et al. Poster presented at the 25th American Pain Society Meeting; 2006; under the age of 18. No dosage adjustment is recommended for elderly patients relevant, are: Very common (≥1/10): Headache, somnolence, nausea, dry mouth. May 3-6; San Antonio, USA. solely on the basis of age. However, as with any medicine, caution should be Common (≥1/100 and <1/10): Weight decrease, palpitations, dizziness, lethargy, 3. Lilly. Cymbalta [EU] Summary of Product Characteristics, July 2013. exercised. Data on the use of Cymbalta in elderly patients with generalised tremor, paraesthesia, blurred vision, tinnitus, yawning, constipation, diarrhoea, 4. British Pain Society, Pain Assessment and Management Pathways: Neuropathic anxiety disorder are limited. Use with caution in patients with a history of abdominal pain, vomiting, dyspepsia, flatulence, sweating increased, rash, Pain. Available at http://bps.mapofmedicine.com/evidence/bps/index.html mania, bipolar disorder, or seizures. As with other serotonergic agents, serotonin musculoskeletal pain, muscle spasm, dysuria, urinary frequency, ejaculation Acccessed 6/6/13 syndrome, a potentially life-threatening condition, may occur with duloxetine disorder, ejaculation delayed, decreased appetite, blood pressure increased, treatment, particularly with concomitant use of other serotonergic agents, as flushing, falls, fatigue, erectile dysfunction, insomnia, agitation, libido decreased, described under ‘Interactions’ (below). Caution in patients with increased intra- anxiety, orgasm abnormal, abnormal dreams. Clinical trial and spontaneous Adverse events should be reported. Reporting forms and pain ocular pressure or those at risk of acute narrow-angle glaucoma. Duloxetine has reports of anaphylactic reaction, hyperglycaemia (reported especially in diabetic been associated with an increase in blood pressure and clinically significant patients), mania, hyponatraemia, SIADH, hallucinations, dyskinesia, serotonin further information can be found at: hypertension in some patients. In patients with known hypertension and/or syndrome, extra-pyramidal symptoms, convulsions, akathisia, psychomotor www.mhra.gov.uk/yellowcard. other cardiac disease, blood pressure monitoring is recommended as appropriate, restlessness, glaucoma, mydriasis, syncope, tachycardia, supra-ventricular Adverse events and product complaints should also be especially during the first month of treatment. Use with caution in patients arrhythmia (mainly atrial fibrillation), hypertension, hypertensive crisis, December 2013 Vol 11 No 4 l Pain News 265 whose conditions could be compromised by an increased heart rate or by an epistaxis, gastritis, haematochezia, gastro-intestinal haemorrhage, hepatic reported to Lilly: please call Lilly UK on 01256 315 000.
ISSN 2050–4497 272 Erratum
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PAIN NEWS December 2013 vol 11 No 4 201
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British Pain Society Calendar of Events
2014
Primary & Community Care SIG Meeting Friday 17th January Churchill House, London
Cancer Pain (30th Study Day) Monday 10th February Churchill House, London
Orofacial Pain (31st Study Day) Tuesday 25th March Churchill House, London
Annual Scientific Meeting Tuesday 29th April to Thursday 1st May Manchester Central, Manchester
Musculoskeletal Pain (32nd Study Day) Tuesday 17th June Churchill House, London
Philosophy & Ethics SIG Annual Conference Monday 30th June – Thursday 3rd July Rydal Hall, Ambleside, Cumbria
Patient Liaison Committee – Annual Seminar Thursday 23rd October Churchill House, London
Topic TBC (33rd Study Day) Monday 24th November Churchill House, London
More information can be found on our website http://www.britishpainsociety.org/meet_home.htm Or email [email protected]
00_Prelims.indd 202 12/11/2013 12:24:23 PM PAN11410.1177/2050449713511729RegularsHappy Christmas 5117292013
Editorial Happy Christmas Pain News 11(4) 203 –204 © The British Pain Society 2013 Thanthullu Vasu
In March 2014, I will be handing over this specialties, including nursing, psychology responsibility to a wonderful team of and physiotherapy. At the time of writing of experts and be assured that our this editorial, the Executives have assured newsletter is in a better position than ever. me that all the applicants would be offered The aim of our newsletter is to express a vital role in the newsletter and the the views of our wider multidisciplinary Society. I sincerely thank all the applicants membership and to make our members for their interest in these posts and am sure aware of the excellent work done by the that the newsletter would be in a much Executives, Council and in fact the whole better position with this excellent team. membership. I am thankful to the Council who in the last year have approved two If we don’t change direction soon, more Associate Editor posts in addition We’ll end up where we’re going. to the Editor post. Considering the increasing amount of articles being ‘Professor’ Irwin Corey, Comic submitted and the huge increase in the Film actor and Activist activities of the Society, this has been felt as essential to keep with the pace. In this issue of our newsletter, we are I am happy to inform you that Dr Arasu fortunate to have the transcript of the Rayen from Birmingham has been main lecture of the Philosophy and Ethics selected as the next Editor by the Special Interest Group (SIG) meeting Executive Committee. I am sure our delivered by Dr John Loeser. As many of On behalf of Pain News and our regular readers will know that Arasu has us know well, Dr Loeser is a past Society, I wish you all a Happy contributed regularly to our newsletter via President of the International Association Christmas: his interesting Rayen’s Column for the for the Study of Pain and the American last three years. Being a keen believer in Pain Society; he has edited the famous Time does not change us; multidisciplinary team work for pain textbook Bonica’s Management of Pain. His call for the change in culture of pain It just unfolds us. management, he will be the right person to lead Pain News. Among his excellent management is vital at this present time, Max Frisch, Swiss playwright, credentials include his vital role in the especially with the significant changes in 1911–1991 Committee of the West Midlands Pain the National Health Service (NHS). Society, as Examiner for the Royal I can’t believe that it is already 3 years College of Anaesthetists, being a Course Far and away, the best prize that life since I took over the responsibility of Director for various pain courses, lecturer has to offer editing our newsletter; times have in various national meetings and an is the chance to work hard at work changed, and the same applies to Pain excellent variety of his published articles. worth doing. News also. Thanks to all our members He will be taking over as the new Editor and their contributions, there are more from next April after observing one issue Theodore Roosevelt interesting articles and interactions of our newsletter in full preparation. through our newsletter, and we have We received a variety of applications for With the changes in the benefit system, reached the next step in its evolution now! the Associate Editor posts from various many of our patients have complained of
December 2013 Vol 11 No 4 l Pain News 203
PAN511729.indd 203 12/11/2013 11:27:01 AM Editorial
significant difficulties. We have two about measuring the outcomes! Clare trainees that attended a pain related interesting articles in this issue: Dr Rob Bridgestock and her team from Glasgow study day, the results were not Hampton from Leicester details about the have produced an interesting outcome encouraging. Hopefully, new projects, Fit for Work team, which has achieved measurement after injection study in this including the e-pain and undergraduate significant success in innovating new ways issue. We all agree that it is difficult to education changes, should encourage of uniting the health and social sectors. In measure outcome in many chronic pain and motivate more trainees in pain all, 30 patients on benefits were referred to interventions due to the multiple variables management. their team by Job Centre Plus, and their that could confound the study. We have results and outcome are impressive. I can to appreciate the Glaswegian team for Thanks to the nurses and Nye Bevan see that the pain management their wonderful analyses of outcomes The NHS is quite like heaven programmes have got to adapt with from 2011 to 2012 with more than 800 Provided one confronts the tumour similar innovations if they have to prove to questionnaires and nearly 1,400 be effective and survive! On a similar note, performed procedures. I am of a firm With a sufficient sense of humour. Linda Knott and her team from South belief that database of procedures are a JBS Haldane, Geneticist and Devon have presented a service evaluation vital starting point in outcome Evolutionary Biologist (1892–1964) of their pain management service with measurement after injections or other regard to their ability to meet the patient’s interventions. More impressive are the In my term as the Editor, one of the need to return to work (RTW). A focus results that two out of three obtained notable achievements that I wish to claim group analysis of five patients with RTW 30% reduction in pain and approximately is that I have encouraged few school needs has clearly shown three common one out of three obtained 60% pain relief; students and medical students to write themes: ‘negative perceptions’, having data to benchmark and compare for our newsletter. I have succeeded in ‘knowledge and understanding’ and among ourselves is also vital during this publishing a handful of articles in this ‘problems with the system’. This once era of revalidation. These teams are not category in the recent past. Shruthi again clarifies the need for the link person only using these electronic forms for pain Rayen, school student from Birmingham with knowledge of chronic pain when injections, but have rolled out to measure has presented her view of how humour facing the RTW issues. We thank them for outcome in other areas including can help pain and has written about sharing their ideas and experience, which acupuncture. We wish them all success Hasya yoga. Lucy O’Connor from will definitely help our members. in their aim to also develop and deliver a Manchester University has also I am impressed not only at these two clear algorithm based on this database presented her essay on mind and matter articles with regard to ‘RTW’ issues; also, for interventional pain procedures. linking pain and disability in this issue. in an analysis of spinal cord stimulators I was dismayed by a recent article in I am thankful to all the contributors for by Ruth Cowen and her team at Chelsea the Royal College of Anaesthetists’ this issue, to make it such an excellent and Westminster Hospital, they have not Bulletin (Burnside WS, Weaver M; Christmas issue! A variety of interesting only measured the success in terms of Bulletin 81, September 2013, pp. 25–7). articles from various disciplines of pain pain relief and quality of life but also with The authors surveyed the preference of management – I enjoyed all of them and regard to their achievement of RTW and pain advanced training module among hope you all will also enjoy them; please going abroad on holidays. I feel that all the ST6/ST7 anaesthetic trainees in write back to us about your views, future research in chronic pain should Northern Deanery. Average rating of comments and any other feedback. have quality of life and RTW as their interest for pain module was the least I hope that the New Year 2014 brings primary measurements in addition to pain among all the specialties for advanced you all the courage and confidence to relief to make the study more meaningful. training among the anaesthetic trainees face the changes in our health system in this survey. The rating was only 1.49 in and helps you to continue working hard Man is the measure of all things: a scale of 1 to 4! Although 53 responded for our patients and the specialty. Now, of things which are, that they are, out of 144, it was not encouraging to see enjoy this issue of our newsletter. that only 2 showed interest in pain and of things which are not, that they module. In another interesting study in are not. this issue of our newsletter, Bence Hajdu Protagoras, 490–420 BC and their team have presented a survey among the trainees who attended a Talking about interventions, none can cancer study day in their region. Even Thanthullu Vasu argue with the fact that the future is among this selected group of anaesthetic Bangor, North Wales
204 Pain News l December 2013 Vol 11 No 4
PAN511729.indd 204 12/11/2013 11:27:01 AM PAN11410.1177/2050449713510852From the PresidentFrom the President 5108522013
From the President Dr William Campbell Pain News 11(4) 205 –206 © The British Pain Society 2013
cut health-care expenditure, for example, e-Learning pain reduced health-care contacts, including I have written a little about this project, accident and emergency (A&E) which was accepted as a joint venture by attendances. The official launch for this the BPS and Faculty of Pain Medicine report was held on 29 October in Royal College of Anaesthetists, later in Westminster. this issue. The submission was accepted and funded by the Department of Health e-Learning Programme, and after the National Pain Audit extension hard work of the module leaders and On behalf of the British Pain Society, authors, this system, which is intended Dr Cathy Price, Clinical Lead for the for all health-care professionals, should National Pain Audit, applied for an become live towards the end of this year. additional pain audit to follow on from the work already undertaken earlier this year, and was successful. National Institute for Health Currently, we are not sure how many and Care Excellence years this project will run for, but it is for Currently, we are in the process of at least a couple more, after a 10- to applying for National Institute for Health 12-month gap. This great news will and Care Excellence (NICE) accreditation allow for more detailed outcome of our publications. We will not know the measures and analysis, strengthening result of this application until next spring the case for adequate funding for pain at the earliest. Dr Eloise Carr and more management throughout the country. recently Professor Nick Allcock Currently, the provision of services is established a detailed process which I thought that this year was going to patchy. should be followed in preparing any BPS become quieter regarding activities as the publication for our members or patients. year progressed. My predecessor This has put us in a good position for this Professor Richard Langford with support The British Pain Society application, but we will have to wait and from enthusiastic members of the British Website see how NICE views it. Pain Society (BPS) ran commissioning Over the past couple of years, there were roadshows throughout the country, as well plans to improve the BPS website. We as concluding the current five pain are nearly at a point where we will see Low back pain pathways and having these on the Map of useful changes. Dr John Goddard has During this autumn, there have been Medicine site. In addition, the National Pain now taken a lead on this project, several meetings on the management of Audit has run the planned 3 years now, following on from Dr Rajesh Munglani low back pain (LBP). One has been led and the results make fascinating reading at who has established many new changes by Professor Charles Greenough, http://www.nationalpainaudit.org/media/ that will be needed. We would hope that National Clinic Director – Spinal files/NationalPainAudit-2012.pdf in the near future, information on Disorders, Chair Pathfinder Project – The final report confirms the commissioning can be added, and Low Back Pain and Sciatica. He is devastating impact that chronic pain has together with the Pain Pathways and attempting to produce an agreed on patients lives and how the provision of results of the Nation Pain Audit should flowchart between the health-care adequate pain management can make prove to be a very valuable and readily disciplines and their representative not only real changes in patients lives but accessible resource. bodies. This takes into account the
December 2013 Vol 11 No 4 l Pain News 205
PAN510852.indd 205 08/11/2013 4:17:20 PM From the President
pathways produced by the BPS (which couple of months, before guidance Vasu it is testament to your sterling work were drawn up by a multidisciplinary would be published to replace CG88. that we need several people to replace you. group in any case) and pathways produced by other professional organisations. It is hoped that there will New Editor for Pain News The Secretariat be an agreed flowchart for back pain Dr Thanthullu Vasu has made Dina Almuli stepped in to replace Rikke patients available by the end of the considerable and valuable changes to Susgaard-Vigon during her maternity leave. current year and that this will be Pain News since he started as its editor Dina has done a great job co-ordinating acceptable until there is a replacement a few years back. He will be leaving as features for the forthcoming Annual for the NICE LBP guidance CG88. editor next spring and to ensure that we Scientific Meeting (ASM), including On 3 October, NICE asked have ongoing support for this activity, an changes to the way the ASM is run, stakeholders to a scoping meeting on advertisement for not only an Editor but following members’ constructive feedback. LBP. Professor Mark Baker, Director, two Associate Editors was made Good news, Rikke had a little baby Centre for Clinical Practice, NICE, recently. boy Noah Soren on 26 August – mum chaired the meeting, and Dr Stephen I am pleased to say that there was a and baby both keeping very well. Ward is to lead the project. A workshop very good response to this and that Dr With the increasing number of projects, took place during the morning to Arasu Rayen has agreed to take over as well as the ongoing work for the ASM, establish which disciplines would be best from Vasu after a period of shadow work SIGs, and so on, the Secretariat is under placed to act as representatives on the for several months. We also had a considerable pressure. We are all very clinical guidance group and to evaluate number of applicants for Associate grateful for that extra bit that they do for therapies that might be added to the pre- Editor, representing medical, psychology, the BPS. We plan to have a strategy day populated list that was produced on the nursing and physiotherapy disciplines. after the next council meeting in early day. It was emphasised that it would be Rest assured that we will make full use December to see how we can improve 24 months from now, give or take a of your talents! the running of the Society.
Consultations
Throughout the year, the Society is invited to participate in various consultations relating to pain; in addition to the numerous requests from NICE, the Society has also submitted comments to the following consultations since September 2013;
• Regulations about the new offence of driving with a controlled drug in the body above a specified limit: consultation document (Department for Transport) – submitted 17th September 2013 • D15 Major Trauma Clinical Reference Group stakeholder product testing consultation (CRG) – submitted 30th September 2013. • Scheduling of tramadol under the Misuse of Drugs Regulations 2001 (Home Office) – submitted 9th October • Spinal Cord Injury Product Testing consultation (CRG) – submitted 11th October 2013. • MLX 382 – Consultation on availability of Diclofenac as a pharmacy medicine (MHRA) – submitted 21st October 2013 • Paediatric Cancer User Friendly Service Specification consultation (CRG) – submitted 21st October 2013. • Provision of specialist residential chronic pain services in Scotland consultation (Scottish Government) – submitted 27 th October 2013.
206 Pain News l December 2013 Vol 11 No 4
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From the Honorary Secretary Dr Martin Johnson Pain News 11(4) 207 © The British Pain Society 2013
exactly the same as when I last reported it, familiar with) then I went on to to say the standing at a total membership of 1391 following. (with only very slight changes in the It is my belief that chronic pain is the membership breakdown). We did ratify a one of biggest long term health large list of new members at Council which problems in western society (along with will need to be added – it was interesting hypertension, depression and obesity). that there was only one new Consultant To deal with it we have one of the Anaesthetist (and two trainees) but three smallest groups of dedicated healthcare new GP members, four psychologists, two professionals (compared with other occupational therapists, two medical disciplines) and also generalists physiotherapists and several other are poorly trained in pain. Thus focusing professions! Our multiprofessional nature is only on high level interventions simply our single biggest strength. Welcome to will not work, both practically and new members! financially. I come across so many healthcare professionals that say that self management is very woolly and not Study Days real medicine. I would contend that this Firstly, though I appreciate it wasn’t a is simply because they don’t know what study day, may I give my congratulations information to give the patients and in to the organisers of the PMP Conference particular, how to support them. in Jersey – by all accounts another Unfortunately I also come across many outstanding event. patients that have not been given any In 2014 we have several interesting– Having spent the last few days marveling self management advise and indeed Cancer Pain, Oral Facial Pain (in at the architectural wonders of Florence their clinic letters also do not change recognition of the IASP theme of the year), (another EFIC over), I am now sat in the this view. Self management works1 and Musculoskeletal Pain. Exact details will be plastic bucket seats of a well known low improves health outcomes, physical available either in this edition or later in the cost airline – tickets cheap but you pay functioning and patient experience. year. Please support these events. for everything else – they haven’t yet But this will only happen if YOU believe The Primary & Community Pain SIG started to charge for the oxygen, yet….. in it. are planning their own study day on the So with a gin and tonic in my hand I May I set a challenge? Whatever your 17th January 2014 – the agenda looks am seeking inspiration for this column! occupation within pain, at every grade, if extremely informative and entertaining! My eyes are drawn to a headline on the you don’t know about supported self flight magazine – which is the biggest management – find out and then try it on phobia in the world (affecting businesses)? Commissioning the next patient you see. Or at least give Apparently it is something called The commissioning support document them a copy of the Pain ToolKit2! Nomophobia (my spell checker does a will hopefully have been finalised before As quoted in a NHS publication about cartwheel….). This is the fear of being the latest Pain News is published. I hope self help3 (written in part by a pain without a mobile phone. I am not sure to report on this long awaited document specialist): exactly how this affects businesses but I in the next edition of Pain News. “The role of a doctor is to add life to agree it certainly affects the individual. Do days, not days to life” we see chronic neck pain more because A Challenge! Notes a vast amount of our time we have our I have recently written an editorial for heads bent down looking at screens? 1. http://www.kingsfund.org.uk/projects/ Paineurope but unfortunately this journal gp-commissioning/ten-priorities-for- is not distributed in the UK so I thought I commissioners/self-management - last Membership would finish this column with an accessed 03/09/2013 (Challis et al 2010) Jenny kindly provided me with the latest abbreviated version of my challenge! 2. http://www.paintoolkit.org membership figures at the Council meeting Initially I set the scene about the 3. Promoting Optimal Self Care Dorset and a couple of weeks ago - the figure is increasing pain burden (which we are all Somerset Strategic Authority. 2006.
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PAN511736.indd 207 08/11/2013 4:17:43 PM PAN11410.1177/2050449713510821Can we change the culture of pain management?Can we change the culture of pain management? 5108212013
Vital topic Can we change the culture of pain Pain News 11(4) 208 –211 management? © The British Pain Society 2013
Prof Dr John D Loeser [email protected]
Dr John D Loeser is Professor Emeritus of Neurological Surgery and Anesthesiology and Pain Medicine and was the Director of the Multidisciplinary Pain Centre at the University of Washington from 1983 to 1997. He is the Past President of the American Pain Society and the International Association for the Study of Pain. He was the Assistant Dean for Curriculum at the University of Washington from 1977 to 1982. He is the editor of Bonica’s ‘The Management of Pain’ and has lectured and written extensively on both research and clinical aspects of pain. The following is a transcript of his main lecture at the Philosophy and Ethics SIG meeting at Launde Abbey, June 2013.
chaos with no culture behind it where each provider (mainly private insurers) everybody has their own viewpoint? deciding what they are going to pay for. There are at least ten Pain Societies in So, why the chaos? The first problem is the United States, many with state- or that many people have wrong conceptual region-based chapters. Each one models. There are many physicians who promulgates guidelines, has meetings to are fixated on a biomedical model of present their products and often disease and just cannot conceive of the threatens litigation against people who issue that something outside of a patient’s say or do things that threaten their back may be responsible for their pain interests. You can tell what a pain behaviour. Everybody knows the highly specialist does for a living from the mechanistic Descartes model of the body organisation he or she belongs to. I’m and the fire. That was a pretty good sure in the United Kingdom, you have model for its time, but the Melzack and something similar. I am aware of the Wall Gate hypothesis in 1965 totally revolution you had in the Pain Society revolutionised the way physicians thought because of the President’s agreement to about pain and was a seminal act in standards of care that did not meet the leading to the development of a pain desires of many of its members. If you world. The United States and the United look at the guidelines, you can Second, we lack outcomes data. You Kingdom have very different health-care immediately tell who wrote them, and too are lucky if you can find data for a few systems. Many of the issues that I will many patients get what the provider months, but a year’s follow-up, which is address may be more prominent and does irrespective of what the patient reasonable for a chronic pain patient, is problematic in my country than in yours. needs. There are pain clinics in the ridiculously rare. Without outcome data, But my travels have told me that the United States where 100% of the you don’t have feedback on what your same issues come up in every country I patients get an injection or a surgical interventions do; so, you keep doing the have been in; it’s just the relative procedure without a history taken or a wrong thing over and over again. proportion of which issue is the big one physical examination. Part of the chaos Meaningful outcomes data must involve that changes. and lack of a common culture in our follow-up of at least 6 months to a year country is that there is no standard of or even longer, and include self-reported what should be done before surgery or pain, functional improvement and health- Culture treatment is implemented. We have care utilisation, especially with regard to Is there a culture of pain management? different organisations promulgating medication, work status and quality-of- Or are there several cultures? Or is it just directly opposing the guidelines and life assessment.
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In the United States, physicians are values. Unfortunately, providers and pressured by the need to fund their funders of health care are not immune to practice or the institution in which they these archaic ways of thinking. practice to work in unsatisfactory ways. Unmyelinated axons and damage- They are pushed into seeing more sensitive receptors exist in every animal patients per day and more per hour; so, from the sponges up, but the relevance they don’t have time to listen, and they to human suffering of the teleological fail to pick up on the patient narrative and explanation that pain allows an organism the meaning of life – and their pain – for to avoid tissue damage by triggering the patient. protective and adaptive reflexes might be Then, there are patient expectations. I called into question by a fascinating story can’t tell you how many patients who about angina. This was totally relieved by have said to me ‘I came here because I bilateral thoracic sympathectomies, hear you do laser treatments’; I say ‘for which were the most common what?’ and they reply ‘I don’t care what pain as a medical problem in its own neurosurgical operation done in the first it’s for – I just want the laser treatment’! right was revolutionary. half of the 20th century. It was argued The role of opioids in chronic pain that if the person doesn’t feel the angina, management has become a major issue, The need for pain they won’t know that they had better and we have a new epidemic of Why do people have pain? Why have we stop exercising or they’ll kill themselves, inappropriate opioid use and diversion. evolved as a species with the ability to although there was oodles of evidence There are more deaths in the United perceive pain? There have been already that not perceiving ischaemia did States from prescription opioids than from teleological explanations: it’s good, it not change your outcome one iota. In the heroin, and more than that are killed on protects us from things. There have been modern era, spinal cord stimulation in the our highways every year. About a third to social and moral explanations: the word thoracic region for a patient with angina a half of the deaths are in the person for comes from the Latin Poena meaning is an excellent method of controlling it, whom the prescription was written, and a punishment. In the Dark Ages, the and exactly the same objections have similar proportion in a person for whom it prevalent thought was that sin led to pain been raised, although people with and was not written, commonly a teenager and suffering, and that people were born without stimulators die at exactly the taking his mother’s pills to a party. evil and somehow needed pain and same rate. suffering to make them worthy. Some Does suffering have social uses? Is pain a medical problem? people deliberately endured pain and Perhaps by manifesting it, you enlist the People use the word ‘pain’ to mean suffering to somehow make themselves help of others. It is also suggested that many different things, including suffering. better as human beings. The Renaissance unless you feel pain yourself, you will not Suffering is certainly not always a changed things, and people were have the ability to empathise with medical problem, and for many of our generally thought of as born good and not someone else in pain, and empathy is patients, pain is not really a medical in need of pain to make them better. part of the glue of society. There are some problem and doesn’t require some sort There was an attempt to abolish pain and who believe that somehow it is good for of medical intervention, although it may suffering in the 19th century through the people to suffer, as this makes us better demand some kind of social intervention. development of social organisations and human beings, and that children should Pain was regarded only as a by-product welfare programmes. But in the modern be allowed to suffer a little. Can suffering of disease until before John Bonica. If era of the 20th and 21st centuries, we see be used to allow social controls and teach you look at medical textbooks prior to biomedicine promising the abolition of moral behaviour? 1950, you will never find one that has a pain – a drug that will guarantee you pain C.S. Lewis wrote in the preface to The chapter or a section on pain. Bonica’s relief. Problem of Pain that ‘all arguments in book The Management of Pain published Medicine – perhaps more in the United justification of suffering provoke bitter in 1953 was the first literature in the States than the United Kingdom – has resentment against the author’. His English or any other language on pain. essentially ignored human suffering. We suggestion that without pain and Just as the Melzack and Wall hypothesis have seen progressive limitation of the suffering people would forget their God revolutionised thinking about the basis social resources to deal with it. There are stirred much debate. for pain and strategies for its many people who still utilise ancient, Although suffering has many causes management, Bonica’s push to establish Mediaeval or Renaissance concepts and other than pain, including, fear, anxiety,
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isolation, depression, hunger, fatigue and New England Journal of loss of loved objects, we continue to use Medicine a few years ago of the the language of pain for all kinds of public viewpoint of personal suffering. When people use the language experience versus performance of pain and when they speak of suffering, revealed that although coverage it tells you how they perceive the world and quality of the system were around them. seen to be poor and costs too Suffering is not presented uniquely to high, there was much less health-care providers. Taxi drivers will tell dissatisfaction with personal you they hear a lot of suffering from their experience; respondents thought passengers, as do attorneys, bureaucrats, it was worse for other people. It’s social workers and of course spouses. a very interesting paradox. But physicians tend to ignore suffering, No one argues that the perhaps because of the biomedical United States has a good model, and perhaps because they don’t health-care system, but how to want to ask. There are loose linkages George Bernard Shaw saw this clearly: change it is hotly debated. To between tissue damage, pain, suffering, some degree, we have placed the pain behaviours and the patient’s narrative That any sane nation, having burden of good health on the doctor and – what he says and does – and these observed that you could provide for not the patient. We have people smoking need to be investigated. the supply of bread by giving bakers a who don’t feel they have adequate care pecuniary interest in baking for you for their chronic lung disease. Health care should go on to give a surgeon a has been driven much more by incomes Capitalism and care pecuniary interest in cutting off your than by outcomes. We have what is There is unequal remuneration by leg, is enough to make one despair for called re-imbursement-driven medicine; providers. I, as a surgeon, can generate political humanity. in other words, what gets done by the more revenue in 1 hour in the operating doctor is what gets paid for. room than I can in 8 hours in the pain Preface, The Doctor’s clinic seeing patients with chronic pain. Dilemma: A Tragedy. Conclusion We therefore have a surplus of people So, how can we change the culture of who do procedures and a dramatic This was written 120 years ago. pain management? First, we will need to shortage of primary care physicians who My belief is that the focus of the select different health-care providers. should be the first step in any pain provider must be on the care of the You don’t want surgeons or patient’s evaluation and treatment. patient. Conflicts of interest are anaesthesiologists to be the front line. We have to face the reality of worldwide and exist in every health-care Second, in a capitalist society, you need capitalism: that money motivates system today. ‘Patients’ have become to use capitalist principles to reward behaviour. How and what physicians are ‘consumers’. ‘Doctors’ have become desired behaviour. One third of the paid strongly influences what services ‘providers’. ‘Clinical judgment’ has been American health-care budget is spent on they provide. Money always trumps replaced by ‘evidence-based practice’. administrative costs. We have to eliminate ethics. In our country, the insurance The traditional focus on humanism and the intermediaries who wish to change industry will not pay for multidisciplinary caring has been threatened by the health care into a business. Third, we pain management, even though it is business aspects. The treatment of pain must evaluate functional status, not just known to be the most cost-effective is based on the highest ethical principles self-report of pain, and only then will we treatment available. The quality of care in medicine; it should not be impaired by learn what treatments work. declines when more business pervades transient regulations, fears of retaliation Part of the problem in our country at medicine. It is not just the spectacularly or economic factors. least is that we pick the wrong people bad actors who make the headlines; it is Efforts to reform health care have been to be doctors. We select physicians the everyday practice of medicine that undermined by the public’s ambivalence based on their ability to take tests, has been subverted by the business towards the government and by a rather than their narrative sensibilities. model. The control of medical practice by dichotomy between the perceived overall Another problem is the overwhelming market economics is not compatible with system performance and personal care amount of debt that the medical an ethically based profession of medicine. experiences. A survey published in the students accrue by the time they
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graduate, which forces them to choose be generalists, not proceduralists, and But perhaps, above all, we need to the more remunerative specialities to referral from a pain generalist should be change pain education. Pain must be pay off their debts. required to see a procedural specialist. introduced into the basic professional We have to improve remuneration for Nobody should walk into a pain clinic curriculum for all health sciences. I am primary care physicians to get more and get a block a half hour later. Chronic happy to say that there appears to be people to do that, and most pain pain management is a primary care currently a revolution in American management should be done at the function, and procedural specialists medical schools to make pain part of the primary care level. Pain specialists should should not be the entry point for care. curriculum.
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News Update from Acute Pain Pain News 11(4) 212 –213 SIG – Chest(er) pain © The British Pain Society 2013
Dr Jane Quinlan Chair of the Acute Pain SIG [email protected]
This year marked the 23rd year of the more common, with the crisis mentioned the difficulty of providing National Acute Pain Symposium currently precipitant often being social factors acute analgesia to patients after bariatric held, as for the last few years, in beautiful rather than an acute medical event. surgery where doses cannot be based Chester. The meeting is skilfully Inpatient pain teams are therefore on actual body weight, but he organised by Keith Stevens and his developing skills in managing long-term recommends ideal body weight (IBW) glamorous assistant Georgina Hall, and conditions, and working with GP and plus 40% (IBW = height in centimetres had the usual high standard of speakers community teams to support pain minus 100 for men or 105 for women, to and variety of topics that maintains its patients at home. give the IBW in kilograms). high repute. Mark Rockett also focussed on the Jeremy Cashman from London While some see or consider acute pain importance of good communication with continued the pharmacology theme and as less of a focus, this meeting with over GPs when he highlighted the risks of examined the use of adjuvants to 200 enthusiastic attendees highlights prolonged opioid use in patients enhance pain relief, while Carmen that in-hospital pain management is not prescribed opioids for short-term acute Lacasia-Purroy from Aintree presented only thriving but developing to meet the post-operative pain but who continue to her experience of bridging the analgesic changing needs of an increasingly take them well beyond the period of gap between the cessation of epidural complex patient population. tissue healing. An American study found analgesia and the start of oral step- One of the recurring themes this year that 6% of patients were still taking down by using fentanyl patches. Anton was the overlap between acute and opioids 6 months after they had been Krige from Blackburn considered chronic pain. Mark Rockett from started for post-operative pain.1 Pain whether epidurals still have a role after Plymouth and Richard Langford from severity or duration did not predict colonic surgery or whether they have London discussed the transition of prolonged opioid use. With the known been superseded by the plethora of acute post-operative pain to a chronic risks associated with long-term opioid abdominal wall blocks. He concluded pain state, while Christine Sinclair from use, we must ensure that patients and that laparoscopic techniques mean that South Tees told us of the community- GPs understand the importance of abdominal wall blocks are usually based rapid access clinic they have set stopping strong analgesia once the acute sufficient but that epidurals still have a up for patients with an acute pain resolves. role in more complex open procedures exacerbation of chronic pain presenting The Thursday morning talks ranged or for patients with a chronic pain to the emergency department. Rather from our youngest patients to our eldest: history. than admit the patient to an acute Rishi Diwan from Alder Hey gave a In keeping with the indistinct territories hospital bed, the patient is reviewed in fantastic talk on paediatric pain of acute and chronic pain, we had a the emergency department and given management and touched on the current light-hearted and lively debate as to an appointment for the community controversy over codeine and the whether chronic pain specialists or clinic. This has decreased repeated surprisingly broad decision of the anaesthetists are best suited to treat hospital admissions and provides much European Medicines Agency to restrict its inpatient pain. With impressive more appropriate care for patients than use to children over 12 years of age.2–4 impartiality, I feel that, on balance, I won, a prolonged hospital stay. The audience At the other extreme, Euan Shearer arguing that anaesthetists had the agreed that, with reduced out-of-hours from Aintree gave an excellent overview necessary skills (impatience mainly) to general practitioner (GP) availability and of pain issues in obese patients, manage the challenges of inpatient pain, reduced community support generally, including the interrelation of obesity and that a robust understanding of the emergency hospital admissions for causing pain, and chronic pain and physiology and pharmacology of acute patients with chronic pain are becoming inactivity resulting in obesity. He illness were more important than
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knowing the diagnostic criteria for sensory testing (QST) in assessing the possibility of developing an acute complex regional pain syndrome. Mark musculoskeletal pain and the genetics of pain app. Rockett’s defence of chronic pain pain, respectively. This meeting provides Thank you to all those who attended specialists was noble, but undermined an ideal forum for basic science and made it such a great meeting. I look slightly by his admission of defeat at the researchers to educate and interact with forward to seeing you all next year. outset. The resultant audience discussion clinicians in an informal setting. Special thanks to Andy Vickers, Richard was enthusiastic and came to the rather A business meeting of the Acute Pain Langford, Jennie Hunter and Martin more realistic conclusion that a specific Special Interest Group (APSIG) was held Leuwer who are all valued and staunch interest in inpatient pain was more on the final afternoon. Topics discussed supporters of the National Acute Pain important than a clinician’s background; included the development of the APSIG Symposium. so everyone’s a winner. website to include more links to useful Dr Andrew Moore broke the land resources, the production of a patient References 1. Carroll I , Barelka P , Wang CK , et al . A pilot cohort speed record to arrive in time to deliver leaflet to support patients in managing study of the determinants of longitudinal opioid use an excellent talk on the effect of the their pain at home after discharge from after surgery . Anesthesia and Analgesia 2012 ; formulation of analgesics, whereby fast- hospital (we have the British Pain Society 115 ( 3 ): 694 – 702 . 2. http://www.ema.europa.eu/ema/index. acting preparations may not just be (BPS)) support and are putting together a jsp?curl=pages/medicines/human/referrals/ marketing hype but seem to exert a multidisciplinary group to lead its Codeine-containing_medicines/human_referral_ significant positive influence on the development), the initiation of a research prac_000008.jsp& ;mid=WC0b01ac05805c516f 3. Niesters M , Overdyk F , Smith T , et al . Opioid- effectiveness of the drug. and audit database for APSIG members induced respiratory depression in paediatrics: a We were extremely lucky to have two to collaborate and allow multicentre review of case reports . British Journal of young researchers, Anushka Soni from working (Mark Rockett is research and Anaesthesia 2013 ; 110 : 175 – 82 . 4. Kelly LE , Rieder M , van den Anker J , et al . More Oxford, and Franziska Denk from King’s audit lead for APSIG and can be codeine fatalities after tonsillectomy in North speaking on the role of quantitative contacted at [email protected] ) and American children . Pediatrics 2012 ; 129 : 1343 – 7 .
University of Birmingham Interventional Pain Management Cadaver Workshop
PART 1 PART 2 09 – 11 April 2014 17– 19 September 2014 Lumbar and pelvic procedures Cranio-cervical procedures Neuromodulation and programming Advanced neuromodulation Musculoskeletal US - upper limb and trunk Musculoskeletal US - lower limb and
abdomen
4 DELEGATES PER WORKSHOP, ONE TO ONE TUITION, MAXIMUM 24 DELEGATES New format with increased hands – on time and targeted lectures Lumbar facet joint denervation Cervical facet joint denervation Dorsal root ganglion blocks Cervical nerve root blocks Disc procedures Thoracic splanchnicectomy Sacroiliac joint procedures Trigeminal ganglion procedures Lumbar sympathectomy Sphenopalatine ganglion procedures Hypogastic plexus block Stellate ganglion block
Spinal and peripheral nerve percutaneous lead insertion and specific programming session
SPECIALIST WORKSHOPS Epiduroscopy US guided procedures
Further info: Dr Dalvina Hanu-Cernat Registration: Mrs Lynne Murphy [email protected] Pain Unit Tel: 07976 697761 Nuffield House, 3rd floor Queen Elizabeth Hospital Consultants £900 / £1700 Birmingham Trainees £750 / £1400 B15 2TH Tel: 0121 371 5100 Fax 0121 371 5101 [email protected] DISCOUNTS FOR COMBINED BOOKINGS FURTHER INFORMATION AT http://www.interventionalpain.co.uk/
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News PMP SIG – rehabilitation: Pain News 11(4) 214 –217 moving forward with confidence © The British Pain Society 2013
Dr Paul Wilkinson
Almost two years have passed since I held to account and remain in the the first health-care contact throughout was appointed as the Chair of the Pain spotlight until there is resolution. We all the care pathway to the refractory group Management Programme Special know that there are equal injustices in the who attend an interdisciplinary Interest Group (PMP SIG), and as we area of pain but that people with pain programme. Different levels of risk- approach the twilight of the current often suffer in silence, the lobby is quieter stratified early intervention are followed committee’s time in office, it seems a and the arguments we all know well for by group-based pain management good time to reflect on the work of the the effective treatment of persistent pain programmes or intensive (often committee and pain management in are unequivocal but often complex. residential) programmes where needed. general. I have to say that I have The PMP SIG is fully aware of these Coupled to other British Pain Society thoroughly enjoyed my time on the difficulties and has been working (BPS) documents like the Map of committee and feel privileged to be part tirelessly on your behalf. The document Medicine, there is now very significant of such a resilient, hard-working, Recommended Guidelines for Pain support to help practitioners manage energetic and innovative team. Sarah management for Adults and the negotiations with commissioners. My Wilson, Dee Burrows and Kerry Mathews accompanying participant document aim here is to notify you of the existence have been astonishing in their hard work has been radically updated. This is now of these documents which will undergo and dedication, supported by our wider an evidence-based document with each a formal launch separately. I wish to committee members. statement supported by an evidence thank deeply the working group on this Immediately, I must thank all those rating. The role of individual document; this group strived to get the who attended, facilitated, lectured and programmes of care is acknowledged balance right for appropriate, not organised our recent SIG conference in as well as the importance of ‘back-to- contrived consensus. Jersey at the ‘Hotel de France’ on 26 work’ strategies. Self-management is a We now have a completed update of and 27 September 2013. The conference therapeutic approach that begins with the Directory of PMP teams throughout the was magnificent, a true ‘tour de force’, but more of this later! I will start with the business of the PMP SIG. In a climate of unprecedented political change in health care, there is a sense of anxiety by many. The challenge in the rehabilitation of people with pain is common to pain care in general. In a health-care system of infinite demand and finite resource, without due diligence, there is a danger that the allocation of health-care resource is most influenced by crisis rather than coherent planning. A long queue in accident and emergency, a late diagnosis of cancer, an intensive care patient without a bed – all grab the public like a vice. Managers are
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Table 1. Key achievements and future planning
1. PMP Directory Completed Updated the National Directory to be updated regularly in the future 2. PMP Guidelines Completed The SIG will formulate a launch, implementation, dissemination and review policy in due course which is posted on the web site 3. ASM SIG Joint Workshop Submitted and gained acceptance for a joint workshop with the Interventional Pain Medicine SIG for the next AGM in 2014 4. HRG Coding – Update We have encouraged members to use the HRG coding system but have shared concerns that the current codes may not generate enough income to support PMPs especially if doctors are included. In addition, many services are commissioned directly so using the codes centrally to measure activity will lead to significant underestimation 5. PMP Conference Guidance Refined our process of support for this conference from the SIG committee to produce a guide and procedure for local organisers 6. Role of committee officers + committee communication Formally defined the roles of the SIG officers and duration to improve succession planning 7. Newsletter Initiated a brief Newsletter to improve communication with membership 8. E-Learning Coordinating rehabilitative components of the Department of Health E-Learning project
PMP: Pain Management Programme; SIG: Special Interest Group; AGM: annual general meeting; HRG: Healthcare Resource Group.
United Kingdom. Thanks to Suzie Williams say that we always understand the Table 2. Committee members. and all who assisted her. Teams have perspectives of others? Do all members committed to using the evidence-based of pain teams have a complete working Main Medical Dr Paul Wilkinson document within this process. While knowledge of all interventions? At the next (Chair) variation in interventions for people with British Pain Society Meeting, we will be Alternate Medical Dr David Laird pain is highly desirable, based on individual having the first Joint Workshop between Past Chair Dr Frances Cole need and local demographics, variation in the Interventional Pain Medicine SIG and Main Psychology Dr Kerry Mathews practice can weaken negotiation for the PMP SIG. Judging by one or two (Secretary) resources. The PMP SIG is confident that communications, a few were highly Alternate Dr Zoe Malpus there will be more unity in our approach to surprised, but all have universally Psychology self-management in the future and a clear welcomed this! Clearly, only one small Main Nursing Dr Dee Burrows path has been set. We know we have not area can be covered, but the aim of this captured everyone in the Directory. If your workshop is to integrate and coordinate Alternate Nursing Joanne Hurt programme is missing, can you inform the our thinking. If you answered ‘yes’ to all of Main Sarah Wilson BPS Secretariat as we hope to update this the previous questions, then there is Physiotherapist (Treasurer) more frequently. clearly no need for you to attend! Alternate Despina Karagyri In this account, I have so far discussed However, I would challenge you to reflect Physiotherapist Pain Management but not wider pain further! I would like to thank Manohar Main Occupational Deanne Barrow treatments. PMPs are an integral part of Sharma from the Interventional Pain Therapist interdisciplinary care. It is imperative that Medicine SIG and Kerry Mathews for Alternate TBA we put equal energy into integrating pulling this together. Occupational different types of treatment into coherent I have summarised the key recent Therapist treatment plans. Can we say that this achievements of the SIG in Table 1. Link to Council Heather Cameron always happens, all the time, everywhere? Behind the headline news, there is Patient Liaison Colin Preece Within our interdisciplinary teams, can we much more. We have a Newsletter for
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SIG members and have strengthened From left to right: rare animals at the Gerard Durrell wildlife centre – Dr Paul guidance to PMP SIG conference Wilkinson, Dr Mick Thacker, Professor Lorimer Moseley and Dr Iain Jones organisers for what is now a large-scale conference, and we have strengthened our approach to succession planning within the SIG. We have recently contributed to the relevant pain management sections of the E-Learning on the Department of Health (DOH), a crucial joint BPS and faculty project. But alas, there is still so much more to do! Now over to the Jersey conference and more fun things! The PMP SIG holds this two-day conference on topical issues every two years, but this is the first time that this conference has been held off the mainland. I believe that there could have been no better venue than Greve de Lecq this beautiful Channel Island and thank the Jersey local committee for their enormous efforts in hosting such a conference and for overcoming many logistical issues along the way). The group worked tirelessly and imaginatively to ensure the economic viability of the conference in what is clearly an increasingly difficult financial climate. I must specifically mention Alessio Agostinis, Julia Morris, Rosy O’Doherty, our event manager Sara Clews and all the support from the BPS Secretariat. I also wish to thank the committee members who supported this process and the many contributors and partners both in industry and locally as well as Speakers and organising team Dee Burrows, and Sarah Wilson (Table 2). The Jersey team assembled a formidable list of speakers and developed themes that are crucial to the challenges of everyday practice. It is rare for such national and international speakers to be assembled in the pain management field. Our invited international speakers, Professor Lorimer Moseley from Australia and Professor Mick Sullivan form Canada gave riveting talks as did all our speakers local to home. Important themes were participant-centred outcomes, evidence- based consultation, perceived injustice,
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mindfulness, activity management and considerable media coverage (radio and captured here mainly by my good friend the role of the immune system. TV), and the opening speeches were by and colleague Sailesh Mishra. I concede We were supported financially and the deputy High Minister and the Minister that despite my best efforts, he has logistically by Jersey Employer’s Network for Health! We got a real Jersey much more talent them me in this area on Disability (JEND) and the Jersey welcome! Finally, I leave you with the and a better camera! Conference Board. They secured lingering memories of Jersey Island
e-Learning in pain
Dr William Campbell
In September 2009 an application for a multidisciplinary e-learning programme in pain was made to the Department of Health e-Learning for Healthcare programme (2010-2011). Ann Taylor led on this for the British Pain Society. The Faculty of Pain Medicine joined in the application, which was successful, having both a Royal College and a multidisciplinary Society behind it. The programme was not intended for Basic pain management completed. To all of the authors we the pain specialist but rather all Basic science extend a big thank you. healthcare professionals so that they Treatments (pharmacological and In total there are 72 sessions, of these could recognise unrelieved acute and non-pharmacological) 15 are existing e-LA sessions. chronic pain. In addition the appropriate Acute pain Although I mentioned that these staff could then assess and manage the Musculoskeletal pain modules are aimed at the non-specialist pain in a safe and effective manner using Neuropathic pain in pain medicine, they are so current best practice. As I mentioned in Other chronic pain comprehensive that they make a good the last issue of Pain News, we are Special populations primer for any clinician starting out in their indebted to Julia Moore, National Cancer pain training in acute, chronic or cancer pain! Director of e-LfH who chaired the regular The actual programme will be available meetings and of course the module The authors, too many to mention at the end of this year / early next year, but leaders, who drove this project. There here, devoted many hours to writing the launch date is the 3rd December 2013 were many authors covering the resulting each section and without their dedication at the Royal College of Anaesthetists, modules: this work could not have been Churchill House, London, by invitation.
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News Pain relief in Uganda Pain News 11(4) 218 –220 © The British Pain Society 2013 Dr Barbara Duncan [email protected]
After retiring from the National Health service. She realised the great need for supported by colleagues such as Service (NHS) last year, I found myself care of the dying elderly, began teaching Dr Jagwe (a Ugandan senior physician), working as a volunteer doctor for about this and set up a palliative care worked tirelessly in advocating palliative Hospice Africa Uganda (HAU), where I team. care and the provision of morphine for met some inspirational people. After her mother’s death in 1982, Anne pain relief in sub-Saharan countries. In worked in Malaysia as Associate 2003, Anne was awarded a MBE for her Professor in Penang and Senior Teaching work on relief of pain throughout the Fellow in Singapore. She became aware world. of the ethical issues of discharging Education is a major role for HAU in patients home with incurable illnesses expanding palliative care and pain relief and no treatment or no pain relief. Anne throughout sub-Saharan Africa. In 2009, set up a volunteer service in Singapore, the Institute for Hospice and Palliative which became the main Home Care Care (IHPCA) was accredited by the Service providing pain relief and holistic National Council for Higher Education in care. Uganda as an institute of Higher In 1990, Anne was invited to become Learning. IHPCA, developed from the Medical Director of Nairobi Hospice in education department of HAU, provides Kenya. She witnessed terrible suffering of short and long courses for a wide range patients presenting with advanced of health-care professionals, including a cancer. Many could not reach degree course in palliative care. radiotherapy or oncology services. Dame Changing of legal statutes to allow Cicely Saunders, Anne’s inspirational nurses to prescribe morphine, followed force, asked her to write about African by training nurse prescribers, was a palliative care. Subsequently, a number major step for HAU in providing Anne Merriman of African countries invited her to develop accessible pain relief. Nurse-led Professor Anne Merriman grew up in palliative care services. After a feasibility palliative care is the foundation of Liverpool. When she was 13, she saw a study to find a suitable African country, African palliative care due to the film about medical missionaries working Anne and her small team, founded HAU shortage of doctors. in Africa and knew that is what she in 1993. The purpose was to develop a HAU sowed the seeds for the Palliative wanted to do. On leaving school, she sub-Saharan African model of palliative Care Association of Uganda (PCAU; in joined the Medical Missionaries of Mary care that is affordable, accessible and 1999), the Makerere Palliative Care Unit (MMMs), and as a nun ran a medical culturally acceptable. In its 20 years of (MPCU; in 2008) and was one of the laboratory in their hospital in Ireland. existence, HAU has cared for 21,818 founding members of the African Then MMMs arranged for Anne to train people. Provision of strong analgesics is Palliative Care Association (APCA). These as a doctor at University College, Dublin. crucial. One of the main tasks in African organisations are working together to She worked as a missionary doctor in countries is to work with governments to reach the common aim of palliative care South East Nigeria for 9 years returning change legislation allowing morphine into for all in need in Africa. to the United Kingdom to look after her their countries, educating health-care At 78 years of age, Anne now focuses mother. Anne focused on Geriatric workers to prescribe and administer on HAU’s International Programmes Medicine becoming Consultant and morphine safely, and producing visiting many countries each year. Last Head of Geriatric Medicine at Whiston inexpensive oral solutions of morphine year, she visited Cameroon, Ethiopia, Hospital where she revived a failing for patients to self-administer. Anne, ably Nigeria, Sierra Leone, Congo Brazzaville,
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Congo Kinshasa, Cote d’Ivoire and in Zambia taught her that experience was Julia was one of the founding Malawi. Although Anne is no longer a needed before even thinking about members of APCA and their Deputy member of the MMMs, sensitivity to the working or teaching overseas. Julia knew Director from 2007–2010. This role had spiritual needs of patients and their she wanted to return to Africa sometime. provision of essential medicines, families, regardless of their faith or After completing training, Julia worked including analgesics in African countries beliefs, is an abiding passion. Anne firmly on the oncology ward at Hammersmith at the heart of it. Her current role at believes that this means ‘being present’ Hospital and in time became a Lecturer Makerere University in Kampala involves for every individual while stripped of the at the Royal Marsden Hospital. On clinical supervision of the palliative care professional persona. Being there simply researching an article about nurse team at Mulago Hospital (National as one human being caring for another. consultants, she came face to face with Referral Hospital for Uganda) and In 2011, Anne Merriman and Julia an advert for a post at the Mildmay teaching courses that include access to Downing were appointed Professors in Centre in Kampala. Mildmay was set up morphine as a priority for pain relief in Palliative Care at Makerere University. in 1998 to provide quality HIV/AIDS care, adults and children. Pain relief is always treatment, training and education. This top of the list because barriers to job had her name on it, everything fell accessing morphine can at times appear Julia Downing into place, and she felt this was her insurmountable. The fears and stigma of Professor Julia Downing had always calling. Her Christian faith is at the core addiction and abuse still outlaw wanted to train as a nurse at Guy’s of her being, and listening to God’s morphine in many countries. Through her Hospital. Guy’s suggested she should do desire for her is a driving force in her life. work with APCA, Julia has helped lead a degree course that they couldn’t offer. So, in 2001, Julia moved to Kampala workshops on drug accessibility and She gained her degree in nursing at and set up the education and training availability, and develop plans to address Cardiff where she was lucky enough to centre at Mildmay. At this time, there was barriers to morphine access in East, experience two student electives that limited antiretroviral (ARV) treatment West and Southern Africa. She also have influenced her career. The first was available for HIV/AIDS, and adults and helped develop the APCA African at St Christopher’s Hospice, a choice children were dying daily. This was a Palliative Care Outcome Scale (POS) and that was made after witnessing a dying difficult time for everyone involved with the developing paediatric POS (POS – patient being shunted into a side ward caring for people with HIV/AIDS. This has the only outcome measure for palliative and then simply left there. Julia found this changed with the advent of generic care validated in Africa). She is a board distressing. No one actually knew what ARVs. member of the International Association to do for someone they couldn’t cure. A One of her passions is paediatric of Hospice and Palliative Care (IAHPC) friend of hers died in St Christopher’s palliative care, originally stimulated by and a Research Fellow at the Cicely and that experience was a stark contrast. becoming link nurse for adolescents as Saunders Institute, Kings College, Her second elective in a mission hospital an oncology nurse at Hammersmith. She London. is involved with the International In 2007, Julia completed her PhD that Children’s Palliative Care Network looked at the impact of palliative care in (ICPCN) and has developed e-learning rural Uganda (Rukungiri). This led to programmes on pain assessment and access of morphine, strong analgesics management for children. Julia has also and pain assessment in patients. A quote worked in Serbia for the last 2½ years from her research by a health-care after being invited by the Serbian worker says it all: ‘We don’t assess pain Government to train staff and capacity because we can’t do anything about it’. build palliative care services throughout the country. Mhoira Leng Julia’s personal motivation is caring for Dr Mhoira Leng is the Head of MPCU. people at a difficult time in their lives. In She was born in what is now West her own words, ‘My heart is for people Papua. Her parents were medical who are dying’. She saw that although missionaries in the jungle there, but she she could help a few people through her grew up in Scotland. As a medical own clinical work, she could reach even student at Aberdeen University, Mhoira more through training and teaching by went back to her roots in West Papua on equipping others to provide care. her elective.
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involved through short visits and teaching excellence that improves access to support. This experience helped her to quality, evidence-based palliative care for learn about international pain and patients and families. MPCU runs a palliative care, and develop her own skills clinical service that is integrated within in working and teaching internationally. Mulago Hospital, carries out research, Interestingly, pain and palliative care training and capacity building and services are fully integrated in some parts develops future leaders in African of India. palliative care. MPCU and HAU train In 2006, Mhoira left the NHS and set medical undergraduates in palliative care up Cairdeas International Palliative Care introducing the principles of pain relief. Trust. She became its Medical Director in Mhoira has also valued the privilege to order to provide expertise and support have visited and taught in 10 countries in for developing palliative care services. Africa. She is a Board member of the Mhoira then moved to India to work with IAHPC and Honorary Lecturer at Pallium India, colleagues in Christian Edinburgh University, working in Medical College, Vellore, and other collaboration with the Global Health centres. She spends 1–2 months in India Academy. Mhoira is a mentor on the She’s passionate about how every year, mainly training and mentoring International Leadership Development unacceptable it is that so many in the colleagues in North and East India where Initiative, now run from OhioHealth world are without medical and palliative there are very few palliative care services. (formerly the San Diego Institute of care among all the other global She has taught in 16 states in India and Palliative Care). inequalities. Mhoira is motivated by her is a life member of Indian Association for Her passions are for value-based Christian faith. The sharing of our Palliative Care. In 2008, Makerere education, curriculum development, common humanity fuels her desire to University invited her to develop an mentorship, empowerment and alleviate suffering. Mhoira describes academic model for palliative care in the developing sustainable, integrated being humbled daily while working government hospital. HAU later invited modes of palliative care in government alongside some of the most vulnerable her to work with them in the settings. Her inspiration comes from who, in their turn, are the best teachers. development and delivery of the degree seeing those she has been privileged to Mhoira qualified in palliative care and programmes. Mhoira was the founding work with begin to lead, train and took up a consultant post in Aberdeen. lead of MPCU, and trained 27 link ward develop others. Although this job was incredibly nurses (to liaise with MPCU) as well as One of Anne Merriman’s favourite challenging and stretching, she took pharmacists in Mulago Hospital and sayings is that African palliative care opportunities to be involved in developed palliative care protocols that needs people with ‘fire in the belly’ to international palliative care with short include basic approaches to pain relief. develop and deliver its service. There is teaching trips to Belarus and Ukraine. In As an academic unit within internal no doubt that these three people fulfil 1999, she visited India and met medicine at Makerere University, the aim that description and are an inspiration to Professor MR Rajagopal, and remains of MPCU is to operate a centre of us all.
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News Updates from Pain in Developing Pain News 11(4) 221 Countries SIG: Essential Pain © The British Pain Society 2013 Management
Clare Roques Chair of the Pain in Developing Countries SIG, Member of the EPM UK Working Group [email protected]
Many of you will be aware of an sponsored by the British Pain Society UK-based instructors in parts of Africa in educational initiative called Essential Pain (BPS) and the AAGBI Foundation, has the first instance. In order to facilitate Management (EPM), created by Roger recently been run in Mulago Hospital, this, we are compiling a database of Goucke and Wayne Morriss with the Kampala, Uganda. An account of this volunteers who are interested in teaching Australian and New Zealand College of project is planned for a future edition of in EPM workshops. If you would like to Anaesthetists (ANZCA) and their Faculty Pain News. be included in this list or would like to of Pain Medicine. You may also have The increasing worldwide popularity of assist the development of EPM in other seen a version of this call for interest EPM workshops and the need to spread ways, please contact us via Dawn Evans article in the publication ‘Transmitter’, the the workload has led to the creation of a at the FPM ([email protected]). If you have newsletter of the Faculty of Pain UK-based EPM Working Group, which contacts in Africa or experience of Medicine of the Royal College of has the support of the FPMRCA Board, teaching in Africa, we would love to hear Anaesthetists (FPMRCA). the BPS Council and the EPM Sub- from you. More specific details regarding EPM provides a set of workshops Committee of ANZCA. The remit of this the EPM workshops, including some aimed at improving pain management working group, led by Douglas Justins, sample, basic, course materials are through education in basic principles and Kate Grady and myself, is to coordinate available at http://www.anzca.org.nz/ the identification of local barriers to future EPM workshops to be run by fpm/fellows/essential-pain-management. delivering effective care. A vital component is the early handover of the teaching of EPM to the local health-care Call for volunteers workers. A standard EPM course is completed in just three days. Initially designed for low resource settings, EPM has now been run in many countries and several continents, with support from various organisations, including ANZCA, the World Federation of Societies of Anaesthesiologists and the International Association for the Study of Pain. I contributed to a set of EPM workshops in Malaysia; Douglas Justins taught on an EPM course in Myanmar and Jonny Rajan, an anaesthetic trainee, assisted We are looking for UK based instructors who are interested in teaching pain management on an EPM course in Nepal. The in an overseas setting. Association of Anaesthetists of Great Please contact Dawn Evans at the FPM ([email protected]) if you are interested in finding Britain and Ireland (AAGBI) supported out more about this project or would like to be included in future correspondence related both Douglas and Jonny’s trips to Asia. A to the work of the EPM UK Working Group. series of EPM workshops, generously
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News Northern Ireland Pain Commissioning Pain News 11(4) 222 –223 Meeting © The British Pain Society 2013
Dr Pamela F Bell Chair, The Pain Alliance of Northern Ireland [email protected]
On 10 September, health-care professionals, carers and patients from all regions of Northern Ireland gathered for a Pain Commissioning Meeting at Riddel Hall. The event was a joint venture of the British and Northern Ireland Pain Societies, the Long Term Conditions Alliance Northern Ireland (LTCANI), the Patient and Client Council (PCC), the Northern Ireland Confederation of Health and Social Care Commissioning meeting speakers From left to right: Happy panellists From left to right: Mrs Louise Skelly, Organisations (NICON) and the Pain Dr William Campbell; Dr Pamela Bell; Mrs Sarah Director of Operations, Patient and Client Council; Dr Alliance of Northern Ireland (PANI), Muckle, Consultant in Public Health, Kirklees; and Dr Pamela Bell, Chair, Pain Alliance of Northern Ireland; working in partnership with the Pain Martin Johnson. and Dr William Campbell, President BPS. Therapy Group of the Association of the British Pharmaceutical Industry, Northern Ireland, who provided financial aid and and a coherent strategy for delivery of services were sustainable. Their logistical support. services that are accessible and strategy has been effective in early The meeting opened with a appropriate to their needs. This survey intervention and when assessed against presentation of the preliminary results of has gathered an immense amount of the World Health Organization (WHO) the survey of patient experience of pain data. This first publication goes to the model of health has demonstrated its and pain services (both primary and PCC Board for approval on 15 October; effectiveness. There are many lessons secondary care) carried out by the PCC. further analysis of the data by region of for Northern Ireland arising from this ‘The Painful Truth: 2,500 Patients Tell domicile, age, gender and diagnosis is and much discussion ensued – their Story’ makes difficult reading for planned. particularly around the use of health those who practice in this field, but really Delegates then heard from Sarah trainers as part of the early intervention holds no surprises. Patients report that Muckle, Consultant in Public Health, strategy. they often feel ignored, disbelieved and Kirklees, about the approach that they Dr William Campbell introduced the patronised by health-care professionals. had adopted to transform services to Map of Medicine and the British Pain Many wait years to get a firm diagnosis those who suffer long-term pain. The Society’s role in developing the Pathways of the cause of their pain, and feel basis of their work was a joint strategic of Pain. Dr Martin Johnson elaborated on dissatisfied with the care that they needs assessment to identify those these as he demonstrated how they receive. The impact of the pain on their most vulnerable to the effects of long- could be used to inform commissioning work, social and family lives is clear, as is term pain. They worked closely with of pain services at both primary and their frustration with the lack of their population and developed a range secondary care level. signposting or referral to appropriate of strategies to support patients in self- The afternoon finished with round table services. They would like to see management of their pain and provided discussions to determine the actions that education and training in pain education to general practitioner (GPs) delegates wished to be taken to most management for all health-care and other health-care professionals, improve pains services. Of these, the professionals enhanced, better support particularly in primary care and three deemed most important for to allow them to manage their condition community settings, to ensure that the immediate action were education for GPs
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and health-care professionals at every development of a regional strategy for for Long-term Pain for Northern Ireland. level of the system, health-care funding pain. Follow-up meetings will be arranged to be identified for Condition Since the meeting, along with the with the intention that the CMO, or Management Programmes currently Chief Executive and the Director of perhaps the Minister, will announce this funded by the Department of Operations of the PCC, I had a lengthy at the official launch of ‘The Painful Employment and Learning (but funding meeting with the Chief Medical Officer Truth: 2,500 Patients Tell their Story’ in under threat) and better engagement (CMO); during this meeting, we the spring. The anticipated time to with colleagues in the Public Health presented the results of the PCC develop the framework is 6–9 months. Agency. In the longer term, key survey of patient experience. He is now Perhaps by next December’s issue objectives were a single point of entry in of the opinion that there is value in the of Pain News, we will be able to services for pain management and the development of a Strategic Framework present it.
BPS responses to National Institute for Health and Care Excellence (NICE)
The Society is a generic stakeholder for National Institute for Health and Care Excellence (NICE) guidelines. The Society is also a generic stakeholder for Interventional Procedures and Health Technology Assessments for NICE. Since January 2013, the Society has received over 90 communications from NICE on topics with relevance to pain. Of those, the Society has formally responded to the following topics:
• Lubiprostone for the treatment of chronic idiopathic and opioid induced constipation – Scoping Workshop attended. • Lubiprostone for the treatment of chronic idiopathic and opioid induced constipation – Scoping Consultation Feedback • Lubiprostone for the treatment of chronic idiopathic and opioid induced constipation - Consultation Feedback • Headache Quality Standard - Consultation • NICE Peripheral arterial disease Quality Standard topic overview – Consultation • NICE Quality Standard for Headache - Endorsement • Neuropathic Pain Guideline Consultation - Consultation • Sickle Cell Crisis – Quality Standard Consultation • Peripheral arterial disease quality standard - Consultation • Lubiprostone for treating chronic idiopathic constipation [ID725] and lubiprostone for treating opioid induced constipation in people with chronic, non-cancer pain [ID646] – Advance Notice of Single Technology Appraisal. BPS to respond when it opens. • Osteoarthritis (update) Guideline - Consultation • NICE Scoping consultation: Naloxegol for treating opioid-induced constipation [ID674] - Consultation • NICE Sickle Cell Crisis Quality Standard - Consultation
If any BPS members are aware of current or forthcoming NICE consultations and they would like to contribute to the BPS responses. Please contact the secretariat at: [email protected]
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News British Society for Rheumatology Pain News 11(4) 224 launches major awareness raising © The British Pain Society 2013 campaign
Painful, debilitating, and costly, rheumatic weeks following the onset of rheumatic will raise awareness about the conditions can make even the simplest symptoms, which often occur in the symptoms of inflammatory arthritis tasks — such as eating, brushing your prime of life, are known as the ‘window resulting in quicker diagnosis and teeth and driving a car — impossible. of opportunity’. If patients are seen prompt treatment.’ The British Society for Rheumatology during this critical time, as soon as Tracey Hancock, Director of launched the campaign Simple Tasks. possible, but certainly within the first Development at the National Rheumatoid Simple Tasks is a national awareness weeks of experiencing early symptoms, Arthritis Society (NRAS), said ‘The Simple campaign to help people understand the we can help ease their suffering and Tasks campaign is so important to raise negative impact of diagnosing and treating avoid long-term complications.” awareness of what is often an invisible rheumatic conditions, outside what is Laura Guest, CEO, British Society for condition, but one which has a major recognised as the ‘window of opportunity’ Rheumatology, added: “Musculoskeletal impact on all aspects of life, not just for – the first 12 weeks after onset of and rheumatic conditions affect up to the person with rheumatoid arthritis but symptoms. The later diagnosis and 16 million people in the UK, yet their whole family too. The ability to carry treatment is received, the greater the rheumatology receives little recognition in out every day ‘simple tasks’ is something chances of permanent damage, pain and health policy – this must change. It’s we all take for granted, but for those disability. There are many rheumatic important that the scale and severity of affected by rheumatic conditions it is not conditions, including rheumatoid arthritis, these conditions is properly understood always the case.’ ankylosing spondylitis, gout, and lupus. The and the priority of rheumatology is Judi Rhys, Chief Executive at Arthritis average time taken to diagnose ankylosing increased to a level proportionate to its Care, said ‘Musculoskeletal and spondylitis is currently eight years and for burden on both patients and the NHS. rheumatic conditions have the potential rheumatoid arthritis this is nine months. This Our Simple Tasks campaign aims to to ruin lives. Yet we know that prompt goes some way to demonstrate how these achieve just that.” treatment makes a massive difference, and other musculoskeletal conditions Debbie Cook, Director of the National not only to the quality of life for the severely limit quality of life for millions of Ankylosing Spondylitis Society (NASS), individuals affected, but also to the people and account for the loss of 10 said ‘Currently many people with economic burden that results from late million working days every year. ankylosing spondylitis have symptoms and inappropriate treatment. The Simple Chris Deighton, President, British for years before a diagnosis is made. Tasks campaign is crucial in highlighting Society for Rheumatology, said: “The first NASS hope the Simple Tasks campaign this important issue.’
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Rayen’s column Do fish feel pain? Pain News 11(4) 225 –226 © The British Pain Society 2013 Dr Arasu Rayen Birmingham [email protected]
the physical and emotional components of vertebrate and invertebrate. Zimmerman5 of pain. Can we apply this definition in all defined pain as ‘an aversive sensory the species? Do animals consciously feel experience caused by actual or potential pain and suffer emotionally like humans? injury that elicits protective motor and If so, how do we explore and prove the vegetative reactions, results in learned emotional component in all the species? avoidance and may modify species-specific Even though there is evidence that behaviour, including social behaviour’. animals feel ‘emotional pain’, some Broom6 defined pain simply as ‘an aversive scientists believe that some animals, sensation and feeling associated with which do not have the neocortex, do not actual or potential tissue damage’. Ellwood7 feel the emotional component of pain. put forward the following list for assessment Thomas Nagel, an American philosopher of pain in other species (other than human). has debated this subject when exploring The species I know one thing: that I know nothing, the question ‘What is it like to be a bat?’ but the others don’t even know that He concluded that unless one goes in to •• Have a suitable nervous system and —Socrates the head of a bat, we do not know receptors; whether the bat feels emotional pain.3 •• Show physiological changes to We were happily cycling along the canal Another problem is that of argument – painful stimuli; towpath on a nice sunny Sunday when by – analogy. Pain assessment and •• Display protective motor reactions we saw two anglers sitting and patiently studies in humans look at change in that might include reduced use of an waiting for their catch. As we crossed physical, behavioural and physiological affected area such as limping, them, we saw one of them catching a parameters. If I accidentally burn my finger, rubbing, holding or autotomy;ii fish with his fishing rod. Suddenly, my I would expect myself to scream, possibly •• Have opioid receptors and show daughter asked me ‘Does this fish feel cry, speedily move my finger away from reduced responses to noxious stimuli pain daddy?’ Instantly, I responded ‘No, the flame and search for a tap to cool my when given analgesics and local fish do not feel pain’. However, this got finger. I should also have corresponding anaesthetics; me thinking. ‘Do fish feel pain?’ physiological changes like increasing heart •• Show trade-offs between stimulus Pain is one of the most vital, primordial rate and blood pressure and sweating. It is avoidance and other motivational survival sensations. It warns animals expected that animals in pain would show requirements; about the imminent danger and therefore similar behavioural, emotional and •• Show avoidance learning; enables them to protect the species. It physiological pattern like human beings. •• Show high cognitive ability and has also been suggested that pain Can we apply this anthropomorphism in sentience (bring conscious). increases the fitness of the experiencing assessing pain in animals?i animal and plays a major role in the Another confounding phenomenon is 1 ‘survival of the fittest’. If pain sensation that some species don’t show any sign is so imperative for survival, do fish and of distress even in severe mutilation. The all living species – vertebrate, mating ritual of an insect called the invertebrate and plants – feel pain? praying mantis is an enthralling example of this.4 After mating, the female praying The dilemma mantis eats the head of the male insect. Pain is defined by International Even during and after this cannibalistic Association for the Study of Pain (IASP) act, the male insect continues to as ‘unpleasant sensory and emotional copulate with the female without showing experience associated with actual or any sign of distress. Does this mean that potential tissue damage or described in the male insect does not feel pain? terms of such damage’.2 As per this Biologists have found difficulties in definition, the organism should feel both defining and assessing pain in lower forms
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Pain in vertebrates an open letter by 36 leading There is less confusion about whether investigators disqualifies the higher order, non-human vertebrates feel above belief that plants have a pain. They vocalise and produce central nervous system with physiological responses comparable to neurotransmitters. They stated humans. However, there are still doubts that they were ‘concerned with as to whether lower order, non-human the concept behind this vertebrates are able to feel pain. Sharks argument’ and added that ‘plant and rays do not have C fibres, which are neurobiology does not add to vital for pain perception. Other fishes our understanding of plant have around 5% C fibres. Due to either physiology, plant cell biology or lack of or less amount of C fibres and not signaling’.13 well-developed brain, scientists believe Based on the available best evidence that fish cannot feel pain. animal with certainty, the balance of Earlier studies in fish showed evidence the evidence suggests that most •• It’s unlikely that plants, fishes or that fish have a conscious pain invertebrates do not feel pain. The cephalopods feel pain perception. An experiment showed that evidence is most robust for insects, electrically shocked toadfish grunted, and, for these animals, the consensus and subsequently, it grunted by merely is that they do not feel pain. Notes looking at the electrodes.8 Rainbow trout i. Anthropomorphism: attribution of human motivation, characteristics or behaviour to inanimate objects, was shown to rub their lips along the The document mentions that even animals or natural phenomena. sidewall and the floor of the tank after ii. Autotomy: spontaneous casting off of a limb or other though cephalopods have a larger brain applied with venom and acetic acid. body part, such as the tail of certain lizards or the compared to other invertebrates, they claw of a lobster, especially when the organism is Contrary to the above, a recent review have shorter life span; there is no injured or under attack. article concluded that fishes are unlikely parental care, most of them are to experience pain.9 The authors also cannibalistic and they don’t exhibit any References criticised that the evidence reviewed 1. Bateson P. Assessment of pain in animals. Animal signals to show that they are in pain.11 were limited by their methodology. Even Behaviour 1991; 42: 827–39. 2. Loeser JD, and Treede R-D. The Kyoto protocol of though the scientific world is still IASP Basic Pain Terminology. Pain 2008; 137: uncertain about this issue, Germany and 473–7. Switzerland banned ‘catch and release’ Oh, one last thing! 3. Available online at http://organizations.utep.edu/ portals/1475/nagel_bat.pdf fishing as it is considered inhumane.10 We have considered both vertebrates and invertebrates, but what about 4. Available online at http://www.youtube.com/ watch?v=KYp_Xi4AtAQ plants? Do they feel pain? Earlier 5. Zimmerman M. Physiological mechanisms of pain Pain in invertebrates researchers like Sir Jagdish Chandra and its treatment. Klinische Anaesthesiol Most invertebrates do not possess Bose stated that plants are aware of Intensivether 1986; 32: 1–19. 6. Broom DM. Evolution of pain. In D Morton, and complex central nervous systems like the the surroundings and are able to feel EJL Soulsby (eds) Pain: Its Nature and vertebrate. Scientists strongly feel that this pain. The venus flytrap senses when a Management in Man and Animals: Proceedings of group of organisms lacks the tools and fly perches on its trap and instantly the Royal Society of Medicine International Congress Symposium Series, vol. 246. London: the ability to feel pain. Exceptions to this clamps shut. A plant called ‘touch me The Royal Society of Medicine, 2001, theory are arthropods (insects, not’ closes its leaves when it is pp. 17–25. crustaceans and arachnids) and modern touched. Do these actions point 7. Elwood RW, Barr S, and Patterson L. Pain and stress in crustaceans? Applied Animal Behaviour cephalopods (octopuses, squid and towards plants having a sensory Science 2009; 118(3): 128–36. cuttlefish). Cephalopods have a highly awareness? Does this mean plants 8. Dunayer J. Fish: Sensitivity beyond the captor’s developed central nervous system with have sensory awareness? grasp. The Animals’ Agenda, July–August 1991, pp. 12–8. similar features to vertebrates. This leads Plant neurobiologists believe that 9. Rose JD, Arlinghaus R, Cooke SJ, et al. Can fish us to the belief that this group should be plants have a nervous system with really feel pain? Fish and Fisheries. Epub ahead of able to feel pain. Some countries were neurotransmitter, glutamate receptors, print 20 December 2012. DOI: 10.1111/faf.12010. 10. Available online at http://www.chattanoogan.com/2008/ even forced to re-evaluate their legislation synapses and electrical conduction. The 5/8/127519/Switzerland-Bans-Catch-And-Release.aspx on animal welfare, for example, the vascular system in plants is considered 11. Available online at http://www.parl.gc.ca/content/ sen/committee/372/lega/witn/shelly-e.htm Canadian government, in their statement to be the nervous system, which 12. Available online at http://ds9.botanik.uni-bonn.de/ declared that transmits the signal throughout the plant. zellbio/AG-Baluska-Volkmann/plantneuro/ The neurotransmitter in plant nervous neuroview.php 13. Alpi A, Amrhein N, Bertl A, et al. Plant although it is impossible to know the system is called auxin, which has an neurobiology: No brain, no gain? Trends in Plant subjective experience of another active vesicle transport.12 Nevertheless, Science 2007; 12(4): 135–6.
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Professional perspectives From Pain to Prospects? – helping Pain News 11(4) 227 –230 people on welfare benefits with © The British Pain Society 2013 chronic pain
Dr Rob Hampton GP and Occupational Physician, Clinical Director, The Fit for Work team, Leicester [email protected]
The main mantra surrounding the Health and Social Care Bill is to ‘break the silo mentality’ between health and social service provision. As a general practitioner (GP) with an interest (GPwSI) in chronic pain and occupational medicine, it has always been evident that many people on long-term health-care benefits with chronic pain would benefit from better co-ordination of their health- care and employment support if they are to re-join the workforce. In my role as the Clinical Lead of a social enterprise called The Fit for Work Team, I’ve had the opportunity to explore this further in Leicestershire. This article describes the work we’ve done with people where chronic pain is a barrier to employment. This work has confirmed the suspicion that there is significant unmet health-care need for many people out of work with chronic pain, particularly for those on to account for 15%–25% of people on their ability to work, and one of the key long-term welfare benefits. We believe Employment and Support Allowance recommendations was that ‘The the findings lend themselves to formal (ESA) (Department for Work and Department of Work and Pensions research. They certainly have implications Pensions (DWP) in 2008). Most of these should consider how to support people for those planning the provision of health- will have a chronic pain component to in pain through specific provision of care and rehabilitation to people with their disability. A report by The Work vocational rehabilitation’. chronic pain, expected to find work as a Foundation in 20121 puts the figure consequence of the evolving welfare higher at 60%. This report identifies that system changes. the silo mentality between health and The Fit for Work Pilots – for employment/welfare provision is typical those in employment Pain as a cause of long-term of most European countries and The Fit for Work Team is a GP-led social sickness absence recommends urgent remedial action if enterprise in Leicestershire. Our work Most chronic pain disorders would be people with painful disorders are to stay started out with the DWP funded Fit for regarded as a disability by the Equality within the workforce. The National Pain Work Pilots from 2010 to 2013. The Act 2010. In the United Kingdom, Audit2 reported that most people service took referrals from local GPs to musculoskeletal disorders are estimated attending pain clinics have problems with provide case-managed vocational
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rehabilitation to prevent long-term years of data were published in July clinical governance leads. The Medical sickness absence and the flow of people 2013.4 The return-to-work outcomes for Defence Union raised a number of onto welfare benefits. In all, 94% of people with health problems fell short of questions before going ahead. The local Leicestershire practices referred to the target by over 70%. Only 5% had found Research Ethics Committee considered service, which achieved nearly 70% work in two years. The message is clear; the pilot and agreed with our view that retention in the workplace. The six UK people with health-related barriers to this process was not formal research. pilots were the forerunner of the National work are not currently served well by the Health and Work Assessment and Work Programme. Initial assessment Advisory Service (HWAS) to be launched There was an emphasis on an ‘intense’ in 2014.3 This will ensure that all people initial evaluation where each person receiving fit notes for longer than 4 From Pain to Prospects Pilot – spent around 1½ hours with the team. weeks will have access to an helping people with chronic Each person was allocated a case independent occupational health pain on benefits to return to manager whose role was to motivate and opinion. work co-ordinate their journey towards The Leicestershire data support the We were lucky in Leicestershire to have employment but also to help with non- findings of the National Pain Audit, with 1 good support from Jobcentre Plus (JCP) medical problems affecting their lives in 4 of the 1,026 people with completed throughout the Fit for Work Pilot for those such as debt or low self-esteem. episodes through the service reporting in employment. The question was In all, 40 minutes was set aside for the chronic pain as a ‘significant barrier’ to whether a similar approach could clinical assessment by the GPwSI, and work. Nearly half of these reported succeed for those on benefits? Our all people were examined. This was often chronic pain as their only barrier. social enterprise successfully applied for their first examination for many years! A third of these people found that ‘a a ‘proof of concept pilot’ through the painDETECT5 was used as part of the better understanding of my pain’ was a JCP ‘Flexibility Fund’. We wanted to assessment. Examination findings were significant factor in helping them return explore whether people on welfare recorded to categorise the pain to work. It was interesting to note that benefits with chronic pain fare better in syndrome. Standards were used for several people had an undiagnosed an attempt to return to work if tentative diagnoses. For example, the neuropathic component to their pain ‘Budapest’ criteria for Chronic Regional resulting in GP correspondence to 1. A doctor with an interest in pain Pain Syndrome6 or American College of advice treatment to National Institute for management spent quality time with Rheumatology (ACR) scores7 for Health and Care Excellence (NICE) them at the outset; fibromyalgia were used with a view to guidelines. 2. A pain management programme validating any findings and (PMP) is combined with employment communicating recommendations to the support and job matching; person’s GP. The Work Programme 3. A case manager follows progress and The consultation with the GPwSI The government’s Work Programme was helps with other hurdles to a return to concluded with an agreed plan of action launched throughout Great Britain in June work. to help address the pain. Where an 2011. It is part of the government’s welfare unmet health need was agreed, there to work reforms and aims to help people Our plan was to take 30 people on were three clinical approaches: on benefits back into work. The principle is benefits by referral from the JCP to incentivise employment support and Disability Employment Advisors (DEAs). 1. PMP; rehabilitation by offering a payment by These people cited chronic pain as a 2. Individual physiotherapy; results system that rewards investment into significant barrier to work. The service 3. Communication to GP of new helping those with complex health was voluntary, and it had to be made tentative diagnosis and/or treatment problems. Alongside this programme, there clear that benefit status would not be recommendations. is a wholesale review of people who have influenced by participation or outcome. been on ESA for many years with a view to We also paid great attention to The final part of the assessment was returning many people to Jobseeker’s document informed consent, requests to meet a dedicated employment advisor Allowance (JSA) and to find work. for clinical information and confidentiality from B-working, part of a local charity, So how does the current provision of within the process. The process was who could look at skills and aspirations employment support for people with approved by the Leicestershire Local with a view to training, job readiness and chronic pain measure up? The first two Medical Committee (LMC) and local job-matching.
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PMP there are already four people in paid Satisfaction surveys from service users Following a competitive tender, the PMP employment, three in voluntary work and have been positive so far, even for those was commissioned from the University of one in training to set up her own who have dropped out of the service. Leicester Hospitals’ Pain Department business. Our current projections are to The theme of bringing health-care and delivered at Voluntary Action exceed the targets with 14 people in one expertise closer to the process of finding Leicester where the Fit for Work Team is of the three categories. work has been welcomed. based. The programme was delivered to the British Pain Society (BPS) standards over six sessions by a physiotherapist, Themes to emerge Future possibilities occupational therapist and clinical The team was encouraged from an early We believe that the From Pain to psychologist. As far as we know, this is stage by the feedback from the JCP Prospects Pilot is an illustration of the sort the first example in the United Kingdom DEAs who consistently reported how of collaborative working across social and of JCP funding being utilised to provide motivated people were after first health-care sectors that underlies the targeted and co-ordinated specialist assessment. The majority of people to intentions behind the new Health and National Health Service (NHS) health care enter the service had failed applications Social Care Bill. The project still has four to people with health barriers to for ESA or been taken off health benefits. months to run to completion, but our employment. Typically dispirited, cautious and even local JCP has already asked us to explore Nearly two-thirds of people (19) were angry, it was pleasing to hear that the similar models for cardiac and pulmonary found to be appropriate for PMP. In all, initial assessment put most people in a rehabilitation for people on long-term 16 were put forward to the programme ‘better place’ towards considering a benefits. We are also in the early stages with nine completing the full 6 sessions. return to work in the context of their pain. of looking into how to scale up the Improvement in function and reduced One of the ‘jewels in the crown’ of this existing service, for people with pain, into impact of pain were improved for all project has been the success of bringing a more sustainable model. NHS England people finishing the PMP. evidence-based intervention from plan to introduce ‘value-based Leicester Hospitals’ Pain Department into commissioning’ in the coming months. a community setting through the PMP. This combines the value that an individual Unmet health needs Participants and practitioners have been patient derives from health-care The clinical assessments uncovered positive about this service in the context interventions with the value of that clinical patterns consistent with of moving closer to the workplace. investment to the whole population. previously undiagnosed myofascial pain Case management of complex cases Reducing the suffering from pain towards syndrome, fibromyalgia or a neuropathic is an emerging theme in health care re-joining the workforce would seem to component to pain in over half the cases. generally and in occupational health in be a compelling package for such Undiagnosed complex regional pain particular. The From Pain to Prospects commissioning. But where is the syndrome was identified in three of Pilot revealed a significant need for evidence? these. The findings and motivation, encouragement and in some A frequent criticism of much of the recommendations from the assessment case, a certain amount of shepherding, current service provision to people on resulted in communication with GPs for towards addressing the barriers to a welfare is that lack of research evidence 22 cases. These were to consider new return to work. So far five people have to support current practice. As a clinician diagnoses (7), request alternative dropped out of the service with no hoping to bring mainstream health care treatment options (4) or both (11). Copies prospect of a return to work. This closer to those on benefits with unmet of the letter were also sent to the patient. number would certainly have been health needs, it is clear that we need to The case managers encouraged people higher without the support and human encourage formal research into future to see their GPs soon after, and qualities that our case managers plans. The aspiration of the Fit for Work recommendations for treatment were put provide. team is to continue innovation in service into place in every case. The willingness of GPs to accept and delivery with a view to attracting implement treatment recommendations academic rigour and research evidence Return-to-work progress is encouraging. The response to to solutions that seem to be successful JCP set a target to place four people in medication for a neuropathic component on a small scale. For example, the paid employment, four in voluntary work has been mixed, but where positive, has volume of ‘missed diagnoses’, and four in vocational training. A total of been a significant factor in a return to particularly around a neuropathic 6 months into the 10-month project and work. component or sensitisation problem,
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lends itself to validation by independent Health and Social Care Bill should sickness absence’. January 2013, http://www. pain specialists in any future work. We’re combine to facilitate such change. The dwp.gov.uk/sickness-absence-review 4. DWP. Work Programme – official statistical summary, looking into options for research funding From Pain to Prospects Pilot has tested a https://www.gov.uk/government/organisations/ and hope to continue work with Leicester model to see whether it would work. department-for-work-pensions/series/work- Hospitals’ Pain Department towards this Together with our colleagues at Leicester programme-statistics–2#the-latest-release (2013). 5. Freynhagen R, Baron R, Gockel U, et al. aim. Hospitals’ Pain Department, we hope and painDETECT: a new screening questionnaire to The scene seems to be set for targeted believe that this joined-up approach detect neuropathic components in patients with health-care provision for people with shows promise! back pain. Current Medical Research and Opinion 2006; 22: 1911–20. chronic pain on welfare benefits. Recent 6. Harden RN, Bruehl S, Stanton-Hicks M, et al. changes to the welfare system References Proposed new diagnostic criteria for complex announced at the Conservative Party 1. Making work count – how health technology regional pain syndrome. Pain Medicine 2007; 8(4): assessment can keep Europeans in work. 326–31. conference in October 2013 of December 2012, http://www.fitforworkeurope.eu 7. Wolfe F, Clauw DJ, FitzCharles MA, et al. The ‘mandatory intensive regime for claimants 2. National Pain Audit. Final report, 2010–12, http:// American College of Rheumatology preliminary with underlying health problems’ together www.nationalpainaudit.org (2012). diagnostic criteria for fibromyalgia and 3. Fitness for work: the government response to measurement of symptom severity. Arthritis Care & with the commissioning intentions in the ‘Health at work – an independent review of Research 2010; 62(5): 600–10.
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Professional perspectives Service evaluation – adequacy of Pain News 11(4) 231 –234 aseptic techniques in pain clinic– © The British Pain Society 2013 based procedures
M Chogle Department of Pain Medicine, Ulster Hospital, Dundonald, Northern Ireland [email protected] M Stafford Department of Pain Medicine, Ulster Hospital, Dundonald, Northern Ireland W Campbell Department of Pain Medicine, Ulster Hospital, Dundonald, Northern Ireland D Miller Department of Microbiology, Ulster Hospital, Dundonald, Northern Ireland
Interventional procedures are one of the blocks and carry out the procedures in a Area 2. Epidural injection group, options available to physicians in the dedicated treatment room. We also where swabs were taken before, management of chronic pain. Any perform ultrasound-guided interventions during and post procedure from invasive procedure may be complicated in our clinic. This project was aimed as a patient’s skin. by infection. The risk of infection quality assurance process to evaluate the Area 3. Ultrasound-guided may be enhanced in diabetic and adequacy of various aseptic techniques procedures, where swabs were immunocompromised patients and as a followed in our pain clinic. We looked for taken before and after application of 1 result of steroid therapy. microbiological assessments to appraise ultrasound gel (USG) used for Aseptic techniques are used by the our standards of care and improve or sacroiliac joint or perifacetal health-care professionals to prevent modify our techniques if deficiencies injections. infection associated with these were found. procedures. The goal is to reach asepsis Area 4. USG from sterile single-use which means an environment that is free pouches and bottles were also of harmful microorganisms. Each health- Methods sampled for microbes. care setting has its own set of practices The service evaluation was approved by for achieving asepsis. Faculty of Pain our local research and ethics department, Four sets of samples were obtained from Medicine (FPM) has set the standards of and the project was supported by the each area of interest. A total of 44 good practice for pain clinicians carrying microbiology department. We were samples were collected using a out epidural injections in adults for the allowed a limited number of samples to technique recommended by our management of persistent pain of spinal be processed for quantitative cultures. microbiologist. Microbiologic assessment origin and includes the use of epidural The patients and staff consented for included identification of organisms and injection for the management of acute sampling. All patients received routine quantifying as colony forming units episodes of discogenic and/or radicular care in the pain clinic. (CFUs). pain.1 FPM Best Practice Guidance There were a total of four areas for (published in 2011) states that evaluation: ‘meticulous aseptic technique is Results mandatory and this should include Area 1. Swabs were taken from staff Results shaded in pink in Tables 1 to 3 surgical scrub according to local policy, hands on three occasions (on arrival denote highest potential to cause sterile gown, sterile gloves, cap, and from home, after first and after second infection. Coagulase-negative mask’. hand washing). These three swabs staphylococci (CNS), bacillus and We routinely follow FPM guidance on were collected in an outpatient clinic, micrococcus are mostly skin asepsis while performing an epidural/ between patient consultations. commensals of lower pathogenic
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Table 1. Impact of hand washing on skin flora
Staff Skin swab on arrival from home After first hand washing After second hand washing
1 CNS > 100 CNS > 100 CNS = 16 2 Coliforms = 3; CNS = 5; Gram-negative CNS = 1 No growth bacteria > 100 3 Micrococcus = 1; CNS = 7 Bacillus = 1; CNS = 5 Bacillus = 1; CNS > 100 4 Bacillus = 23, coliforms = 3; Gram-negative CNS = 2 No growth bacteria > 100
CNS: coagulase-negative staphylococci; CFU: colony forming unit. Numbers following the microbes denote CFUs cultured.
Table 2. Impact of chlorhexidine 0.5% on epidural injection site
Patient Baseline skin swab After chlorhexidine spray At end of procedure
1 Pseudomonas = 95; CNS = 2 No growth No growth 2 CNS > 100 No growth No growth 3 Pseudomonas > 50; coliforms = 3; CNS = 8; No growth No growth miscellaneous = 27 4 CNS > 50; miscellaneous > 50 No growth No growth
CNS: coagulase-negative staphylococci; CFU: colony forming unit. Numbers following the microbes denote CFUs cultured.
potential but can cause infection in the The hands of staff are the commonest microbiologic data to reinforce the fact immunocompromised. vehicles by which microorganisms are that we carry potentially pathogenic transmitted between patients.2,3 Hand microbes on our hands on arrival to washing is accepted as the single most clinical areas. Hand washing with soap Discussion important measure in infection control.4 and water on arrival to clinics is as vital A multidisciplinary Pain Clinic setting can Unfortunately, staff believe that they wash as hand hygiene before and after every provide an ideal condition for hands more often than they actually do, patient contact. microorganisms to be transmitted and they also overestimate the duration Chlorhexidine 0.5% with 70% alcohol between those who receive and give of hand washing. Poorer hand washing spray is commonly used for preparation care. Every episode of patient contact, performance was related to increasing of surgical sites because of its efficacy, including out-patient consultation can workload and reduced availability of hand safety and long duration of effect. It is contribute to transmission. decontaminating agents in one study.5 All widely used in the United Kingdom for Pain patients who receive a depot hospitals have invested resources to skin preparation prior to spinals and steroid preparation are vulnerable to get promote hand hygiene. The compliance epidurals. The use of a concentration of infections even with skin commensals. has increased slowly, but laggards are chlorhexidine gluconate more than Patients receiving interventional always seen in all clinical areas. Gloves 0.5% cannot be supported; this procedures for pain management are at are a useful additional means of reducing concentration is evidently effective, but risk of developing infection as a result of hospital acquired infections, but they a greater one might increase the risk of their compromised state of health and supplement rather than replace hand neurotoxicity from inadvertent underlying medical conditions. washing. Our service evaluation used contamination and therefore should be
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Table 3. Before and after ultrasound-guided facet joint injections
Patient Baseline skin swab After chlorhexidine spray At end of ultrasound and gel procedure
1 Gram-positive cocci (non-Staphylococcus) No growth CNS = 1 > 100; CNS > 10 2 CNS = 2; bacillus = 1 No growth Bacillus = 1 3 Environmental Gram-negative bacteria No growth No growth > 100; CNS > 100 4 CNS = 11 No growth No growth
CNS: coagulase-negative staphylococci; CFU: colony forming unit. Numbers following the microbes denote CFUs cultured.
Table 4. Culture of USG gel. Commensals cultured from gel are considered In our hospital, we routinely use a as clinically significant contamination. facemask, gown and gloves for every epidural procedure. None of the skin Sample source Sample 1 Sample 2 Sample 3 Sample 4 swabs obtained at the end of procedure showed any contamination from the Refilled bottle CNS = 4; No growth No growth No growth miscellaneous = 2 operator or the local environment. This Sterile sachet No growth No growth No growth No growth result has encouraged us to continue the scrupulous aseptic technique being CNS: coagulase-negative staphylococci; CFU: colony forming unit. followed in our treatment room. Numbers following the microbes denote CFUs cultured. Ultrasound (USG) has been found to permit bacterial growth and does not have any bactericidal or bacteriostatic avoided.6 Our results showed that showed that surgical masks may properties; so, USG can get easily chlorhexidine 0.5% with 70% alcohol significantly increase the amount of contaminated by pathogens.13 sprayed on to skin resulted in rapid wound contamination. It is postulated Pseudomonas aeruginosa, Escherichia disinfection and no growth was found that under these conditions, skin friction coli and Staphylococcus aureus were all from skin swabs. with the mask may release scales that demonstrated to survive in USG in an Currently, there is insufficient data to carry a significant amount of bacterial in-vitro study.14 Food and Drug make definitive recommendations with contaminants.10 Administration (FDA) recommended that regard to routine gown use in theatre Phillips and colleagues demonstrated the only USG that is sterile is unopened environment during a regional block; that wearing a facemask results in USG containers/packets labelled as however, FPM have recommended using marked reduction in the bacterial sterile. Once a container of sterile or sterile gowns for neuraxial blocks.1 contamination of a surface in close non-sterile gel is opened, it is no longer There is tremendous amount of proximity to the upper airway. Bacterial sterile and contamination during ongoing controversy on the use of facemasks by colonies grew on more than 50% of agar use is possible. Only sterile USG is theatre personnel, specifically during plates placed 30 cm away from providers therefore recommended in clinical performing regional anaesthetic who were speaking without a mask. A practice, where invasive procedures are techniques. Several clinicians quote that fresh mask nearly abolished performed.15 In our hospital, we use facemasks are a critical component of contamination, whereas a small increase bottled gel for casual scanning and asepsis,7,8 whereas others argue that did occur after 15 minutes of wear.10 single-use sterile sachets while their use is not based on definitive Although this increase was statistically performing ultrasound-guided blocks. scientific evidence. A postal survey insignificant, the authors recommend Our service evaluation data showed that reported that 51% of practitioners do not that it may be advisable to wear a new sterile sachets were indeed sterile but routinely wear masks when performing facemask for each procedure or each one of the gel sampled from a bottle epidurals or spinal blocks.9 Schweizer patient encounter.11,12 grew skin contaminants.
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Conclusion following basic hand hygiene and should we use? British Journal of Anaesthesia scrupulous aseptic techniques for 2009; 103(3): 456–7. Microbiological snapshot data collected 7. Tsen LC. The mask avenger? Anesthesia and from our pain clinic highlighted the invasive procedures. A service evaluation Analgesia 2001; 92: 279. following: involving microbiologic data proved to 8. Browne IM. Unmasked mischief. Anesthesia and be a very useful way to appraise our Analgesia 2001; 92: 279–81. 9. Panikkar KK, and Yentis SM. Wearing of masks for 1. Pathogenic bacteria can be found on clinical practice and reinforce good obstetric regional anaesthesia. A postal survey. staff hands and patient’s skin and practice. Anaesthesia 1996; 51: 398–400. 10. Schweizer RT. Mask wiggling as a potential cause ‘Seven Step Hand Washing’ should References of wound contamination. Lancet 1976; 2: be encouraged as an effective tool to 1. FPM of RCOA. Recommendations for good 1129–30. clean our hands before every patient practice in the use epidural injection for the 11. Phillips BJ. Surgical face masks are effective in reducing bacterial contamination caused by contact. management of pain of spinal origin in adults. FPM of RCOA, London, April 2011. dispersal from upper airway. British Journal of 2. Cap–mask–gown–gloves–drape 2. Saloojee H, and Steenhoff A. The health Anaesthesia 1992; 69: 407–8. and chlorhexidine 0.5% with 70% professionals role in preventing nosocomial 12. McLure HA. Surgical facemask and downward dispersal of bacteria. Anaesthesia 1998; 53: alcohol skin spray is an effective infections. Postgraduate Medical Journal 2001; 77: 16–9. 624–6. combination for achieving asepsis for 3. Reybrouck G. Role of the hands in the spread of 13. Muradali D, Gold WL, Phillips A, et al. Can an epidural/ultrasound-guided block nosocomial infections. The Journal of Hospital ultrasound probe and coupling gel be a source of nosocomial infection in patients undergoing in our unit. Infection 1983; 4: 103–10. 4. Larson EL. APIC guidelines for handwashing and sonography? An in vivo and in vitro study. 3. USG sampled from refilled bottles did hand antisepsis in healthcare setting. American American Journal of Roentgenology 1995; 164(6): show contaminants, so we now only Journal of Infection Control 1995; 23: 251–69. 1521–4. 14. Ohara T, Itoh Y, and Itoh K. Ultrasound instruments use sterile gel at skin interface for 5. Gould D. Nurses’ infection control practice: hand decontamination, use of gloves and sharp as possible vectors of staphylococcal infections. ultrasound-guided procedures. instruments. International Journal of Nursing The Journal of Hospital Infection 1998; 40: 73–7. Studies 1996; 33: 143–60. 15. FDA. FDA Safety Communication: update on 6. Cook TM, Fischer B, Bogod D, et al. Response to: bacteria found in other-sonic generic ultrasound Results of our service evaluation Antiseptic solutions for central neuraxial blockade: transmission gel. FDA, Silver Spring, MD, 8 June encouraged the pain team to continue which concentration of chlorhexidine and alcohol 2012.
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Sessions including: Plenary Packages ‐ 5 current topics each packaged into 15min Hyde Park Corner ‐ you bring the topic ‐ audience chooses the session..! Self management Fibromyalgia Monitoring & managing analgesia in primary care ..and much more..!
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Professional perspectives Quality-of-life improvements after Pain News 11(4) 235 –238 spinal cord stimulator insertion for © The British Pain Society 2013 chronic pain
Ruth Cowen Pain Fellow, Chelsea and Westminster Hospital [email protected] Amy Pennefather Medical Student, Imperial College School of Medicine, London Stephen Ward Lead Clinical Nurse Specialist Pain Management, Chelsea and Westminster Hospital Benjamin Thomas Locum Pain Consultant, Chelsea and Westminster Hospital Ian Goodall Pain Consultant, Chelsea and Westminster Hospital Glyn Towlerton Pain Consultant, Chelsea and Westminster Hospital
The National Institute for Health and Care Excellence (NICE) and the British Pain Society (BPS) support spinal cord stimulator (SCS) as a beneficial therapy for certain chronic pain conditions.1,2 At Chelsea and Westminster Hospital, we have been implanting SCS devices for chronic persistent pain for over 5 years. Understanding the importance of outcome data, we followed up our SCS patient population, with a telephone questionnaire. We managed to contact 64% (27 patients) who had devices implanted from September 2006 to March 2012. The majority of patients reported continued significant benefit as perceived by them. The reported outcomes showed improvement in pain manage- ment (85%), mood (63%) and quality of life (78%) years after insertion. Almost half of our patients (48%) had managed to accomplish personal goals, including returning to work and going abroad on holidays. There was a low complica- tion rate and none had a long-term impact. These positive results support the continuation and expansion of SCS implantation within our department.
Introduction relief by SCS involves more than direct neuropathic origin, and the BPS supports Spinal cord stimulation, a form of inhibition of pain transmission in the the use of SCS as part of the neuromodulation, aims to reduce painful dorsal horn of the spinal cord. The multidisciplinary team approach.1,2 sensations by non-painful stimulation of mechanism of spinal neuromodulation is Evidence from randomised controlled the neural pathway. Melzack and Wall,3 only partially described but is likely to trials support the use of SCS in failed with the publication of their gate theory involve supra spinal activity via the back surgical syndrome (FBSS), complex in 1965, paved the way for the use of a posterior columns, alternations of regional pain syndrome (CRPS type 1), variety of stimulation techniques to neurotransmitters such as gamma- neuropathic pain and selected patients manage pain. Initially, peripheral aminobutyric acid (GABA) and with ischaemic pain (refractory angina techniques were trialled, with the first adenosine and a concurrent, pectoris and chronic critical limb report of an implanted device for central pronounced autonomic effect.5 Some ischaemia).2 Trials have shown neuromodulation in 1967 by Shealy et preservation of topographically improvement in pain relief, quality of life al.4 Techniques and equipment, along appropriate posterior column function and a reduction in analgesic usage with understanding of the mechanisms seems to be necessary for SCS to be following SCS implantation.2 As SCS and patient selection, have advanced effective.5 becomes more widely available and enormously since then to develop a National Institute for Health and Care technology advances, other chronic pain spinal cord stimulator (SCS) into an Excellence (NICE) recommends SCS as conditions that may benefit from SCS are effective pain management therapy. Pain a form of therapy for chronic pain of emerging.6 Positive results have been
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shown in radicular pain, phantom limb information and education.11 Assessment Method pain, diabetic neuropathy, post herpetic or further treatment by neurosurgical, We performed a telephone questionnaire neuralgia and ischaemic pain associated orthopaedic or other specialist teams on all traceable patients who have had a with peripheral vascular pain.5,7 may be necessary prior to SCS trial. SCS SCS inserted at Chelsea and Neuromodulation techniques are implantation precludes magnetic Westminster Hospital, London, between concurrently being developed for the resonance imaging (MRI), although new September 2006 and April 2012 for the management of a variety of neurological technologies are being introduced which treatment of neuropathic pain. The conditions, including epilepsy, are MRI compatible. Therefore, the questionnaire was designed to evaluate Parkinson’s disease, movement assessment additionally ensures that most of the core outcome measures disorders, psychiatric diseases and outstanding medical conditions are suggested in the Initiative on Methods, spasticity.8 Professional bodies support investigated and managed prior to SCS Measurement and Pain Assessment in the need for further high-quality research implantation. Those patients who may Clinical Trials (IMMPACT) on the use of SCS.1,2 benefit from a pain management recommendations.12 It included SCS implantation appears to be a programme undertake this in parallel to questions on pain management, safe technique with major complications the SCS assessment pathway. Following functional level (both physical and rare in long-term follow-up.2,9 Minor conclusion of all outstanding issues, the emotional), global quality-of-life complications can occur with relative eligible patients are offered a trial. Those improvements, patient expectations and frequency.2,9 While infection remains of patients assessed during the trial as achievement of goals. We additionally great concern when considering having significant improvement in pain reviewed short- and long-term implantable devices, the most common and functional scores are then offered full complications in order to generate our complications involve electrode lead implantation. We provide ongoing local complication rate. Contact details migration.9 Complications can include follow-up to the implanted patients with were obtained from the hospital records cerebrospinal fluid leakage, spinal additional support from the and verbal consent was obtained from epidural haematoma, neurological manufacturers to allow reprogramming each patient. If no response to the initial damage relating to epidural electrode as required. telephone call was obtained, patients placement, pain related to implanted The benefits of pain management were contacted again up to a maximum device site insertion and technical therapies such as SCS are difficult to of five times. If no response or consent issues such as lead breakage, measure due to the heterogeneity of was obtained, then these patients were disconnection or battery issues. Strict symptoms and subjective nature of pain. classed as non-responders. The adherence to infection control Patient-reported outcome measures are information obtained from the responders measures, including aseptic techniques becoming increasingly important when was analysed. A notes review was and prophylactic antibiotics along with evaluating the effectiveness of therapies. performed on responders to obtain patient education appears to reduce NICE and the BPS recommend long- additional information. infection rates.10 term follow-up and audit of SCS services.1,2 We recognise the importance of follow-up and therefore looked to Results At Chelsea and Westminster assess the clinical effectiveness of our The results are presented in Table 1 and Hospital SCS service. A telephone follow-up of Figures 1 and 2. Implemented by a multidisciplinary team our SCS patient population was in parallel with other therapies, Chelsea undertaken. We used a combination of and Westminster Hospital has been questions to review the effectiveness of Discussion implanting SCS for over 5 years. We treatment focusing on ongoing pain relief, SCSs, trialled and implanted under our currently trial an average of 25 patients ability to self-manage pain, changes in local protocols, are effective long-term annually with an implantation rate over quality of life, expectations and treatment for chronic pain. The majority the last 24 months of 62%. Patients who achievement of personal goals and continue to be effective resulting in may benefit from SCS treatment are global perception of change. Our improvement in pain symptoms (85%), initially assessed in our multidisciplinary intention was to assess the long-term mood (63%) and quality of life (78%) SCS assessment clinic. This service effects of the service we are providing in years after insertion. Significant self- provides psychology, nursing and order to better inform ourselves and our reported improvement in pain symptoms physician assessment as well as patients, and to guide future quality occurred in 85% of patients: 26% some providing verbal and written patient improvement measures. of the time, 48% most of the time and
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had had their SCS over 3 years Table 1. Survey results continued to have improved pain Responded 64% (27/42) symptoms and 87.5% felt their mood Mean follow up time (months) 24 (Range 2-67) and quality of life was improved. Long- Indicators for SCS insertion term benefits from SCS increases the Non ischaemic neuropathic pain: cost-effectiveness of this treatment. It is Back/lower limbs 70% notable that three patients had a SCS Upper limbs 19% inserted for refractory angina pectoris. Ischaemic refractory angina 11% Although there is evidence to support Percentage area covered by stimulation 100%/25 (mode/IQR) this indication, it is not currently a NICE Percentage pain relief 80%/40 (mode/IQR) recommended indication.1,13 Of these Complications three patients, all felt better after their Infection 7%(3) SCS implantation, with over a 50% Catheter migration/fracture 7%(3) improvement in pain symptoms. They felt Thromboembolism (peripheral lower limb) 2%(1) better able to manage their pain, had an improved quality of life and were able to IQR: inter-quartile range. reduce their regular analgesic and coronary vasodilatory medications. Of those patients who reported little Figure 1. Improvement in self- 11% all of the time. Almost half of our benefit from their SCS, one patient management of pain patients (48%) managed to accomplish requested it explanted, two developed personal goals, including returning to pain in sites other than their original site work or going abroad on holidays. Only and one developed chronic pain at the 26% of patients reported improvement in insertion site. Overall, there was a low their sleep. This low figure was found to complication rate and none had a long- be influenced by other medical issues, term impact. Infections are thought to be those patients who didn’t use the SCS the most significant complication, and while sleeping and the fact that some rates published in the literature are patients had no sleep issues prior to between 4% and 10%.14 Infection rates implantation. All those patients (8) who are thought to be influenced by experience of operator, previous spinal Figure 2. Improvement in quality of life surgery and medical conditions such as diabetes.14
Conclusion Spinal cord stimulation is a technology undergoing rapid development for the treatment of chronic pain. As techniques and technology have improved, so has SCS availability. The number of conditions for which SCS or neuromodulation are being trialled is expanding. To establish the effectiveness of pain management therapies, outcome scoring, audit and follow-up of treatments are essential to providing the best and most appropriate therapies to our patients. The results identified in the long-term effectiveness of SCS therapy implanted under our local policies support the continuation and
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expansion of SCS implantation within our 6. Vergani F, Boukas A, Mukerji N, et al. Spinal cord 53-month third party follow-up. Neuromodulation department. stimulation for visceral pain related to chronic 2011; 14(2): 136–41. pancreatitis: report of 2 cases. World Neurosurgery. 11. http://www.britishpainsociety.org/book_scs_ Epub ahead of print 23 September 2013. patient.pdf DOI: 10.1016/j.wneu.2013.09.038. 12. Dworkin RH, Turk DC, Farrar JT, et al. Topical References 7. Mekhail NA, Cheng J, Narouze S, et al. Clinical review and recommendations core outcome 1. http://www.nice.org.uk/nicemedia/ applications of neurostimulation: forty years later. measures for chronic pain clinical trials: IMMPACT live/12082/42367/42367.pdf Pain Practice 2010; 10(2): 103–12. recommendations. Pain 2005; 113: 9–19, http:// 2. http://www.britishpainsociety.org/book_scs_main. 8. Deuschl G, and Agid Y. Subthalamic www.immpact.org/static/publications/Dworkin%20 pdf neurostimulation for Parkinson’s disease with et%20al.,%202005.pdf 3. Melzack R, and Wall P. Pain mechanisms: a new early fluctuations: balancing the risks and 13. Taylor RS, De Vries J, Buchser E, et al. Spinal cord theory. Science 1965; 150(3699): 971–9. benefits. Lancet Neurology 2013; 12(10): stimulation in the treatment of refractory angina: 4. Shealy CN, Mortimer JT, and Reswick JB. 1025–34. systematic review and meta-analysis of Electrical inhibition of pain by stimulation of the 9. Bendersky D, and Yampolsky C. Is spinal cord randomised controlled trials. BMC Cardiovascular dorsal columns: preliminary clinical report. stimulation safe? A review of its complications. Disorders 2009; 9: 13. Anesthesia and Analgesia 1967; 46: 489–91. World Neurosurgery. Epub ahead of print 11 July 14. Mekhail NA, Mathews M, Nageeb F, et al. 5. Yampolsky C, Hem S and Bendersky D. Dorsal 2013. DOI: 10.1016/j.wneu.2013.06.012. Retrospective review of 707 cases of spinal cord column stimulator applications. Surgical Neurology 10. Rudiger J and Thomson S. Infection rate of spinal stimulation: indications and complications. Pain International 2012; 3(Suppl. 4): S275–89. cord stimulators after a screening trial period. A Practice 2011; 11(2): 148–53.
Philosophy and Ethics Special Interest Group of the British Pain Society
Annual Meeting
30 June-3 July 2014 Rydal Hall, Cumbria (www.rydalhall.org)
Compassion in Modern Healthcare: a Community of Care?
To cure sometimes, to relieve often, to comfort always: but have we lost sight of compassion in healthcare? Recent reports have highlighted failures in our healthcare systems: what factors have led to this? Is there a lack of a caring community in the NHS?
The 2014 meeting of the Philosophy and Ethics Special Interest Group will seek to address these issues. Our usual eclectic mix of speakers will present their own viewpoints, providing a springboard for stimulating debate, while the idyllic Lakeland countryside will provide balm for the soul.
Reserve the date in your diary and look out for full details on
www.britishpainsociety.org/members_sigs_philosophy.htm
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PAN511368.indd 238 08/11/2013 4:24:12 PM PAN11410.1177/2050449713511375Informing practiceWaiting times for access to a UK multidisciplinary chronic pain service: how do we comply with IASP recommendations? 5113752013
Informing practice Waiting times for access to a Pain News 11(4) 239 –241 UK multidisciplinary chronic pain © The British Pain Society 2013 service: how do we comply with IASP recommendations?
Quazi Siddiqui Consultant in Anaesthesia and Pain Management [email protected] Girish Rangaswamy Specialist Registrar in Anaesthesia, University Hospital of North Durham
This audit was presented in part as a poster at the British Pain Society Annual Scientific Meeting in April 2013 at Bournemouth
The Montreal Declaration 20101 access to appropriate care within a on Wait-Times proposed the following recognises timely access to pain universally accepted waiting time. To recommendations for access to management as a fundamental human address this issue, International appropriate pain management services: right. Evidence shows that long waiting Association for the Study of Pain (IASP) time for chronic pain treatment is established a task force in January 2009, Group 1. Acute painful conditions associated with significant deterioration in which identified appropriate benchmarks should be treated immediately (e.g. health-related quality of life and for wait-times for treatment of chronic sickle cell painful crises, acute herpes psychological well-being.2 Further pain and endorsed a document in 2010.5 zoster and pain related to trauma or research is necessary to identify the time- In the United Kingdom, there is no surgery); point of the beginning of these agreed guideline for medically accepted Group 2. Most urgent (1 week) – a deteriorations, but it is likely that it would waiting times tailored to different pain painful severe condition with the risk vary for different pain conditions. It is also conditions. Triaging is subjective and of deterioration or chronicity, such as unknown whether the waiting time has generally based on the information the acute phase of complex regional any impact on treatment outcomes. provided by the referrer. The 18 weeks pain syndrome (CRPS), pain in Multidisciplinary treatment remains the waiting for routine/regular referral to children or pain related to cancer or standard of care for complex chronic treatment is generic and not specific to terminal or end-stage illness; pain, leading to decreased use of the chronic pain management. We evaluated Group 3. Urgent or semi-urgent health-care system with significant the current practice of waiting time in our (1 month) – severe undiagnosed or reductions of indirect health-care costs.3,4 multidisciplinary pain management unit, progressive pain with the risk of There are significant differences in the checked compliance with the IASP increasing functional impairment, waiting time benchmarks in different recommendations, analysed possible generally of 6 months duration or less countries causing inequalities and causes for non-compliance and (back pain that is not resolving or confusions among the health-care recommended changes. persistent post-surgical or post- providers and commissioners alike (Table traumatic pain); 1). In order to ensure the fundamental Audit standard human right of pain management as Waiting time is defined by the time Group 4. Routine or regular (8 weeks) recognised by the Montreal Declaration, between referral to initiation of condition- – persistent long-term pain without patients all over the world should have specific treatment. The IASP Task Force significant progression.
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Table 1. Variations in wait-time benchmarks in different countries (extracted Table 2. Patient demographics from IASP document5) Patient demographics Country Triage label and waiting time Total number of 162 Most urgent Urgent Routine referrals Male: Female 1: 2 (53: 109) United Kingdom 18 weeks for all conditions Age (years) 21–87 (mean: 54.14) Australia 1 week 1 month 3 months Canada 2 weeks 1 month 3 months Finland 1 month 3 months 6 months patients in our unit. There are now Norway 2 weeks 16 weeks 16 weeks standardised guidelines/ recommendations regarding waiting IASP: International Association for the Study of Pain. times for specific pain conditions.5 However, the actual practice is likely to Methods judged the appropriateness of the be influenced by availability of local manpower, resources and workload. The We audited consecutive new patient treatment specific for that particular IASP recommends that clinicians should episodes in our multidisciplinary chronic condition for the purpose of audit. be aware of all relevant treatment pain management unit over a 3-month guidelines to direct patients to period. We chronologically recorded the appropriate services in a timely manner. time of first symptom, general Results The Map of Medicine (MoM)6 initiative is practitioner (GP) consultation, referral We collected data of 162 consecutive a major step forward in this regard and is date, postal delay, triaging delay, new patient consultations over a able to provide the up-to-date guideline specialist consultation and initiation of 3-month period. Among them, 112 for the primary care physicians as well as definitive treatment. Majority of the (69.1%) were referred by GPs, 37 specialists. referrals were made through the Choose (22.8%) by consultants of the same and Book system by GPs. Other referring hospital, 3 (1.8%) by consultants from While capacity was a major issue for health professionals include advanced different hospitals and 9 (5.6%) by the the non-compliance with the IASP musculoskeletal practitioners, acute pain advanced musculoskeletal practitioners recommendations of waiting times in our service and other hospital consultants. and 1 from acute pain team of the same unit, cause analysis also revealed that All referrals were initially triaged by hospital (Table 2). average delay for triaging was 2.1 weeks chronic pain consultants and marked as Table 3 shows the number of patients (2 days to 5.7 weeks), which could be either ‘routine’ or ‘urgent’. Although there grouped according to the IASP improved with better referral and triaging is no agreed waiting time for these recommendations and their waiting times system (Table 4). Interestingly, average categories of triaging in the current (from referral to consultation and from delay for triaging urgent cases were system, the central appointment office referral to treatment separately). There longer than routine cases that could be prioritises the ‘urgent’ cases according were 2 most urgent (group 2: IASP- incidental. Nevertheless, it points out the to the availability of outpatient slots. recommended maximum wait – 1 week), importance of early triaging so that Occasionally, a specific waiting time is 20 urgent (group 3: recommended urgent referrals could be picked up for requested for most urgent cases as maximum wait – 1 month) and 140 initiation of treatment sooner. considered appropriate by the triaging routine cases (group 4: recommended It was also felt that other professionals consultant (e.g. acute phase of CRPS). maximum wait – 8 weeks). Overall, the such as specialist nurses or However, as there is no provision of average waiting time from referral to physiotherapists could also do triaging if urgent slot, overbooking the clinic usually treatment in all groups failed to meet the the referral letters were more informative accommodates these requests. We recommendations (8.2, 8.5 and 11.4 and structured. This could potentially recorded the waiting time as defined by weeks, respectively, for most urgent, reduce the waiting time and free up the time from referral to initiation of urgent and routine). consultants to be able to spend more on condition-specific treatment. In cases direct clinical care (DCC). where the treatment was initiated by the Discussion We recommended the following GP or other practitioners before the pain This audit provides a snapshot of the changes towards achieving compliance clinic consultation, the consultants average waiting times for chronic pain with IASP recommendations:
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patients or patients referred by the Table 3. Average waiting times for referral to consultation and referral to allied professionals. treatment in comparison to IASP standards.
Standard Number Referral– Referral– consultation treatment Conclusion The result of this audit shows that the Group 1 Immediate 0 current trend of waiting times in our unit Group 2 1 week 2 6.2 weeks 8.2 weeks for different pain conditions does not Group 3 4 weeks 20 6.5 weeks 8.5 weeks comply with the medically accepted Group 4 8 weeks 140 9.5 weeks 11.4 weeks waiting times recommended by the IASP. We recommended that the triaging delay IASP: International Association for the Study of Pain. should be addressed, and referrers should be encouraged to use Table 4. Triage delay (from referral to triaging) standardised forms using Choose and Book or fax to minimise postal delay. Triage label Number Average delay Range Departmental pathways should be introduced for the management of Routine 142 2 weeks 2 days to 5.7 weeks Urgent 20 2.5 weeks 5 days to 4.5 weeks specific chronic pain conditions (in line with existent guideline such as MoM), and the provision of urgent appointment 1. Standardised referral forms for the consultant (non-consultants would do slots should be ensured. primary care physicians and majority of the triaging). advanced musculoskeletal services. 3. We are working on preparing References These would have enough departmental pathway for specific 1. IASP. Declaration that access to pain management information for the triaging person conditions so that the first contact is a fundamental human right, http://www.iasppain. (consultant, nurse or physiotherapist) could be a different person than a org/Content/NavigationMenu/Advocacy/ DeclarationofMontr233al/default.htm to classify and request central medical doctor (e.g. CRPS patients on 2. Lynch ME, Campbell F, Clark AJ, et al. A appointment office for appointments appropriate anti-neuropathic systematic review of the effect of waiting for accordingly (very urgent, urgent and medications could get a physiotherapy treatment for chronic pain. Pain 2008; 136: 97–116. routine). appointment reasonably early to 3. McQuay HJ, Moore RA, Eccleston C, et al. 2. We are addressing triage delay by initiate desensitisation). This provision Systematic review of outpatient services for encouraging referrers to use Choose is accepted with the understanding chronic pain control. Health Technology Assessment 1997; 1: i-iv, 1–135. and Book, or faxing the urgent that the allied professional has the 4. Weir R, Browne GB, Tunks E, et al. A profile of referrals to avoid postal delay. facility to book an urgent appointment users of specialty pain clinic services: predictors of Previously, consultants triaged their slot with the consultant if necessary. use and cost estimates. Journal of Clinical Epidemiology 1992; 45: 1399–415. own patients only that caused some 4. We have introduced the provision for 5. IASP. International association for the study of pain delay if the particular consultant was one urgent appointment slot (new – task force on wait-times: Summary and on leave. With the new system of 45 minutes) every week that is filled recommendations, http://www.iasppain.org/AM/ Template.cfm?Section=Wait_Times&;Template=/CM/ triaging, we have agreed to triage all up locally by the departmental ContentDisplay.cfm&ContentID=13107 referrals regardless of the allocated administrators to see very urgent 6. http://www.mapofmedicine.com/
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PAN511375.indd 241 12/11/2013 11:42:51 AM PAN11410.1177/2050449713510824Informing practiceDoes the South Devon Pain Management Services meet the needs of patients who report return to work/retention in work difficulties? 5108242013
Informing practice Does the South Devon Pain Pain News 11(4) 242 –250 Management Services meet © The British Pain Society 2013 the needs of patients who report return to work/retention in work difficulties?
Linda Knott Clinical Specialists Physiotherapist Dr Steve Stewart Clinical Psychologist Ingrid Koehler Research Assistant, Torbay [email protected]
The present service evaluation aimed to ‘negative perceptions’, ‘knowledge and Campbell et al.2). Anecdotally, many identify the return-to-work (RTW)/ understanding’ and ‘problems with the patients attending the local pain retention in work needs of patients seen system’. Participants described management services report difficulty for within the pain service. A mixed- perceptions of negative attitudes from staying in, or returning to meaningful methodology approach was used, employers, job centre staff and others work. This, in itself, will impact on their comprising surveys (yielding quantitative and a misunderstanding of their well-being and potential to recover. and qualitative data), and a focus group. capabilities. They also felt that general However, it is not known exactly what An initial survey was developed to practitioners (GPs) and job centre staff the needs are of this cohort of patients, identify the vocational needs of new need further knowledge of the chronic to what extent the health-care clinicians patients seen within the service, and pain, and difficulties with the benefits address these needs or the opinions of distributed for a 12-week period to system were described. Suggestions patients as to what they feel would be physiotherapy and consultants’ clinics. A were made by participants for future most useful to help them to meet their total of 148 surveys were returned service provision. These included the work-related difficulties. (response rate 35.6%), with 69.6% of introduction of a ‘link person’: a worker In 2007, Dame Carol Black patients reporting that their pain had an with knowledge of chronic pain but able commissioned the Peninsula Medical impact on their ability to work. A 3-month to advise and advocate regarding RTW School to scope a pilot project for follow-up survey was sent to the above issues. Limitations of the service developing an early intervention to respondents. When asked about the evaluation are discussed in the report, maximise patients’ ability to RTW or stay ways in which the pain service has and recommendations for future in work when presenting with health helped, common responses included developments are made. problems in primary care. A mixed- ‘being supported to be more physically methods study comprising a literature able’ and ‘addressing concerns about review, in-depth interviews (GPs and damage’. With regard to areas still to be Background occupational health/human resources addressed, common responses included The psychological, financial, social and representatives) and an online survey ‘help to get back to work’ and ‘address health benefits of work and employment (GPs) was undertaken. The aim was to concerns about financial or litigation are fully recognised (Black1). However, establish current evidence for best issues’. A focus group was undertaken the difficulty for patients to stay in work, practice for these patients, and the involving five patients who identified RTW or to RTW after an extended sickness opinions of GPs as to what they felt needs. Three overall themes emerged: absence is also well researched (Black,1 would facilitate recovery (Campbell
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et al.2). The findings endorsed the value evaluation, therefore not requiring ethical developed by all authors, discussed and of an interdisciplinary clinical team to approval. piloted with colleagues. The group was address: medical management of One of the authors (I.K.) identified new held in a non-clinical area of the hospital, underlying conditions, exercise/physical patients from the consultants’ and and facilitated by one of the author (S.M.) training, psychological interventions (e.g. physiotherapists’ clinics via the hospital who had not been involved in the cognitive behavioural therapy) and computer systems. I.K. had previously patients’ clinical care. Informed consent educational interventions (e.g. stress contacted, and where possible, met with was obtained. The discussion was management training). In addition to this, clinic support staff to ensure that recorded and transcribed by I.K. who the GPs advocated that for patients with numbered surveys were appropriately also took notes regarding participants’ musculoskeletal problems, additional distributed to all new patients attending interactions. Thematic analysis was vocational support should possibly be consultants’ clinics. Numbered surveys independently undertaken by I.K. and provided outside of the GP setting were distributed to physiotherapists for S.M., and verified by S.S. Summaries of (Wright et al.3). It was also advised that their new patients at the beginning of the themes were sent to participants, the opinion of patients should be sought. each week. She monitored return rates inviting feedback and comments. In November 2011, the physiotherapy and where possible, prompted staff if and psychology pain management there was a low return rate. Completed Writing the report services were granted £3,885 by the surveys were returned directly to I.K. who Results were summarised by each Torbay Medical Research Fund. This was entered the data on a password- method used and then integrated in the to enable the employment of a research protected computer. To ensure discussion section. This is a recognised assistant to undertake a service anonymity, the unique identification approach when using mixed-methods evaluation of new patients attending number attributed to each survey was approach (Tashakkori and Teddlie4). clinics (doctors and physiotherapists). assigned to the data and the patient’s The aim of the evaluation was to identify personal details removed. Clinic staff whether their presenting pain problem were asked to provide information as to Results was affecting their ability to stay in, or why surveys for individual patients were New patient survey return to (self-)employment (RTW) and not returned. The surveys were A total of 320 new patients were whether input from the pain team had distributed for 12 weeks: October 2012 identified by I.K., with approximately two- met these needs. Respondents were to January 2013. Data were summarised thirds of them being seen by the also invited to attend a focus group to and analysed using descriptive statistics. consultants, and one-third by explore any suggestions that they may Qualitative information was summarised physiotherapists. A total of 44% of the have to enable the team to better meet thematically. surveys were not distributed, and 10% of their needs. the surveys were not completed due to patients failing to attend clinics. A total of Follow-up survey 148 surveys were returned: 35.8% Service evaluation questions All patients who had identified that their (53/148) of the respondents were male. 1. What are the needs regarding RTW/ pain condition had affected their ability to The age distribution is shown in Figure 1, retention in work issues? work were sent follow-up surveys at 3 and for comparison, the age distribution 2. Are we helping them to meet these months. Forms were returned to one of for referrals to pain consultants and needs? the authors (I.G.) and entered on to the physiotherapy is shown in Figures 2 3. What do this group of people feel database. One reminder was sent to and 3. would be useful to help address their non-respondents. A total of 51.4% of respondents RTW/retention in work needs? Data were summarised and analysed (76/148) reported to have had pain for a using descriptive statistics. Qualitative duration of 5 years or more (Figure 4). information was summarised Methods A total of 69.6% (103/148) described thematically. New patient survey the pain as having an impact on their The new patient survey was developed in ability to work (2.9% (3/103) of them the context of the service evaluation Focus group were of retirement age). In all, 49.5% questions and a previous RTW survey. All patients who had expressed an (51/103) of them were in full- or part-time This was trialled with staff and patients interest on the survey were contacted to work or education, none being self- prior to its use. The survey was approved arrange a mutually convenient time for employed. In all, 60.2% (62/103) by Clinical Effectiveness as a service the focus group. Questions were described themselves as not being at
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The final part of the survey asked Figure 1. Age distribution of respondents for survey at first appointment patients what specific help they would (n = 148) and 3-month follow-up (n = 26) like to help them address their needs. Table 1 gives a summary of their 45 responses. 40 The most endorsed question was ‘requiring help to be more physically 35 capable at work’ and was highlighted by s 53.4% (79/148) of respondents. This was 30 closely followed by seeking ‘help to 25 return to work or training’, with 45.9% (68/148) of respondents identifying this. of responeant 1st appt 20 The next two concerns related to 3/12 FU 15 effective use of medication (56/148; Number 37.8%) and addressing concerns about 10 injury or damage (51/148; 34.5%). Issues relating to benefits and/or litigation were 5 endorsed by 27% of respondents 0 (40/148). The remaining six questions 16-25 26-35 36-45 46-5556-65 >65 related to specific issues within the Age range workplace, or trying to stay in work. There were 20 comments written on the surveys, some making more than one point. These were summarised Figure 2. Age distribution (percentage) of respondents to the employment thematically (see Table 2). survey
35.0 Three-month follow-up survey A total of 148 surveys were received from
s 30.0 new patients, with 84 of them identifying 25.0 that pain was having an impact on their ability to work or attend training/ 20.0 education. Follow-up surveys at 3 1st appt 15.0 months were therefore sent to this 3/12 FU cohort, with 29.8% (25/84) being 10.0 returned.
Percentage of respondent 5.0 Age distribution of the 25 respondents is shown in Figure 1. In all, 16 0.0 respondents had seen an additional 16-2526-35 36-4546-55 56-65>65 clinician, with 17 waiting to see an Age range additional clinician. Eight patients had attended a pain management programme (PMP), with 10 reporting that work (medically retired, ‘other reasons’, Of the patients who described that their they were waiting to attend one. signed off sick, unemployed): there was pain problem was having no impact on With respect to employment status, some inconsistency in the answering of training/employment, 61% (25/41) were one was in full-time education, five in full- this question with respect to whether or retired, and only 10% (4/41) were in part- time employment, four in part-time not their pain affected their employment, or full-time employment. In all, 29.3% employment and two were self- and if so, in what way, but further (12/41) stated that they were signed off employed. A total of 10 respondents analysis is described in the next work, unemployed, unemployed due to stated that they were ‘signed off’, and 2 paragraph. other factors or medically retired. were unemployed. All stated that their
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The aim of the focus group was to Figure 3. Age distribution (percentage) of patients referred to the consultant explore patients’ views on their and physiotherapy pain management services (January to June 2011) experience of RTW/retention-in-work issues, and to discuss ways in which 35.0 these issues may be addressed. 30.0 Focus group themes 25.0 Referrals to pain physiotherapy Analysis of the focus group identified three 20.0 (n=299) overall themes: ‘Negative Perceptions’, 15.0 ‘Knowledge and Understanding’, and Percentage Referrals to pain ‘Problems with the System’. Further 10.0 consultants (n=354) details with supporting quotations are 5.0 provided below. In addition, a number of suggestions for service improvement were 0.0 <16 16-25 26-35 36-45 46-55 56-65 66-75 76-85 >86 provided by participants. Age range Negative perceptions. Participants 51.4% of respondents (76/148) had had pain of 5 years or more duration (figure 4) described feeling that other people, including employers and job centre staff, Figure 4. Duration of symptoms for patients returning survey at first may make certain judgements about appointment them because of their pain condition, which may not accurately reflect their 45 sense of their capability to work. It was 40 felt that these judgements may be a bar- rier to returning to work: 35
30 The job centre says I’m 25 unemployable, but I don’t agree.
20 I’m (seen as) an employment risk. It
Percentage colours their judgement. 15 I could do more now mentally, but 10 can’t do it physically, but people won’t 5 accept that. Because I walk funny and 0 move funny … it’s other people’s <3 months 3-6 6-12 1-5 years6-10 years>10 yearsMissing judgements of us, it’s not our months months data judgements of ourselves. Duraon of symptoms People who have health issues feel they will be looked at as off sick and pain was having an impact on their ability Focus group not given a chance. to work. In all, 40% (10/25) respondents As part of the project, a focus group was stated that the pain management team undertaken with five patients who had Participants recognised that there had helped with their RTW difficulties, been seen within the pain management were limitations in the work they could and 80% (20/25) respondents stated that service. Four participants were out of do and difficulties competing with other they would like further help regarding work due to their pain; one was currently candidates who do not have similar their employment needs. The specific working, but was having difficulties health problems: domains are summarised in Figure 5. A staying in work. An additional participant total of 15 respondents wrote a was unable to make the focus group but all those other people you can choose comment, with 26 items identified, emailed the team to contribute some from … you’re going to look for a dog covering five themes (see Table 3). views. with four legs, not two legs.
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Table 1. Summary of responses enquiring into patient’s needs regarding employment or training needs (n = 148; % of all ‘yes’ responses)
Question Yes No Missing data
I would like to be more physically able at work or training (e.g. to be able to sit or 79 (17.3) 14 (2.8) 55 (9.8) stand for long periods, bend, twist or to do heavy or repeated lifting) I would like help to get back to work (paid or unpaid), training or education and 68 (14.9) 24 (4.8) 7 (1.2) resume my usual tasks/activities I would like help to manage my medication better (because I don’t like the side 56 (12.3) 37 (7.4) 55 (9.8) effects/I don’t want to be taking it/it’s not working etc.) I would like to address concerns about re-injury or further damage at work or 51 (11.2) 42 (8.4) 55 (9.8) training I would like help to address concerns about my welfare benefit entitlements or 40 (8.8) 53 (10.6) 55 (9.8) claims, appeals or litigation cases I would like to have the appropriate equipment or the ability to adapt equipment at 33 (7.2) 60 (12.0) 55 (9.8) work or training I would like help to manage my communication or relationships better with people 31 (6.8) 62 (12.4) 55 (9.8) at work or training I would like to be better supported by my workplace or organisation 30 (6.6) 63 12.5) 55 (9.8) I would like to have more satisfaction in my job or training 29 (6.4) 64 (12.7) 55 (9.8) I would like to feel more secure in my job or training 27 (5.9) 66 (13.1) 55 (9.8) I would like help to stay in work (paid or unpaid), training or education and resume 12 (2.6) 17 (3.4) 59 (9.8) my usual tasks/activities
Participants felt that flexible working the point is you have to change It was also reported that the benefits environments would be important, taking preconceived ideas. system does not easily take into account into account the unpredictability of (the person needs to be) much that patients with chronic pain can have chronic pain. more knowledgeable of people who different, but related, health problems: are ill. Knowledge and understanding. if you have 6 or 7 different problems Participants reported that some profes- that overlap, that doesn’t count. Problems with the system. sionals do not have enough knowledge of Participants described difficulties in chronic pain, and of conditions such as finding work: Patient participants’ suggestions for fibromyalgia syndrome (FMS): this includes service improvements. The focus GPs and staff working in job centres: I have applied for 250 jobs, and not group invited participants to provide sug- heard back from one. gestions for service improvements within There’s not enough understanding by the pain service with respect to RTW GPs really of your chronic pain. Participants also reported that provision. These are as follows: I had to take him research about my government legislation and policies illness, he hasn’t got enough hinder patients in getting work. •• It would be good to have a ‘link knowledge of my illness. Participants expressed a concern that if person’ working within the pain Now they’re just starting to get they were to ‘take a risk’ and begin work, management team based in the understanding of it (Fibromyalgia). then it would be extremely difficult to hospital. They could be available for regain these benefits should they not ‘face-to-face’ discussion and would Participants felt that increasing the manage to sustain their employment: have a role as a ‘coordinator’ or ‘case knowledge of relevant professionals (e.g. worker’. This could possibly be a job centre staff) regarding long-term My worry would be that I couldn’t volunteer post, but they would need to conditions, such as chronic pain is cope, and it would be hard to get i.• Have knowledge of the benefits important: back the benefits I had before. system (for form filling), jobs
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Table 2. Thematic summary and examples of comments on first survey
Theme Number of comments Examples
Specific employment issues 8 ‘Normally self employed and P/T but recently moved to the area/unemployed’; ‘Would like to negotiate fewer hours’ Treatment expectations 5 ‘I would like to have a QoL, be free of pain, be able to socialise, be able to have a family, be able to support a family’ Other health concerns 3 ‘Not just the knee pain but COPD, depression etc too’ Financial concerns 2 ‘Be able to support a family’ (as above); ‘Biggest impact – financial risk and incapacity to work’ Work supportive 1 ‘Work are supportive’ Relationship with clinicians 1 ‘I would like my doctor to show more concern’
QoL: quality of life; COPD: chronic obstructive pulmonary disease.
Figure 5. Number of endorsements for each of the domains that respondents felt (a) the pain management team had helped with and (b) they still wanted help with
10
9 Team
s 8 helped with 7
6 Would like
or respondent 5 help with
4
Number 3
2
1
0
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Table 3. Thematic summary and examples of comments on 3-month follow-up survey
Theme Number of Examples comments
Dissatisfaction with input 7 ‘I feel as if I’ve been left to get on with dealing with my pain by myself as I saw the Dr dealing with my pain management in early Nov 2012 & my next appt has been moved back to end March 13. I was given some drugs that really haven’t made any difference. I hoped I would be feeling better by now to be at least able to look for work’ ‘I would like to be pain free or have less pain. The Dr has been very pleasant but treatment so far hasn’t made me better. My health is deteriorating. I am still waiting to start other ideas which I hope helps me start to live more easily and for pain to not be as bad’ Input helped 7 ‘The pain service has helped me to understand my pain and work with it … It’s helped me to do little tasks at home and work out how’ ‘Very positive feedback. The Pain Management Team assured me that my diseases were not “fake.” They told me the “truth” that I won’t get better, but will support me through this. For the first time in 2+ decades I felt like someone was listening to me and on my side. Without their support this year I’m not sure where I would be’ Awaiting further treatment 5 ‘Awaiting lower back injections’ Health concerns 4 ‘I am seeing Dr X on 27 Feb for a follow up and hopefully can talk to him about all my concerns’ ‘All professionals I have seen have been sympathetic but even after an MRI I don’t feel confident about ever returning to health’ Financial/social concerns 3 ‘Lack of paid work makes things difficult as I am solely reliant on my wife’s earnings’ ‘Housing issues’
market and employment sector, low-skilled placements. A more physiotherapists and doctors. As would community and public services, supported and gradual RTW scheme be expected, there was a higher including charities and the is needed with interaction with response rate for people in the 36–45 voluntary sector; prospective employers. years age range, with no one over the ii.• Crucially, they would need to have •• The PMP was useful, but more age of 65 years responding to the some knowledge of pain and emphasis should be placed on RTW 3-month follow-up. In all, 60.2% (62/103) medical conditions; issues. described themselves as being off sick: iii.• Be able to access patient records •• Pain team members need to give this may be high due to a bias of patients to have a bigger picture of the more guidance about how patients who chose to complete the survey and patient’s needs; can get help and what services are had work-related difficulties. iv.• Be able to liaise with patients’ available, as patients tend to feel they Over two-thirds of respondents from employers or human resources have to find things out for the initial questionnaire reported that their and be an advocate for patients, themselves. pain was having an impact on their ability so that they can be supported to to work: of concern, 60.2% (62/103) of stay in work. Discussion them described themselves as not being •• It would be good to offer patients Although a statistical analysis was not in work. Considering that just over half of work experience in work placements undertaken, Figures 2 and 3 indicate that all of the respondents described having or volunteer jobs, particularly within the patients completing the first survey had their pain for five or more years, this the hospital. It was felt that these represented the age demographics of cohort of patients are potentially going to should be ‘challenging jobs’, not just patients seen by pain management be very difficult to re-engage with the job
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market (Waddell5) particularly at a time of by Coole et al.,7 which showed that there ‘knowledge and understanding’ about lowered job opportunities: it is likely that was little evidence that GPs or other chronic pain conditions, and so cannot specialist support would be required clinicians were able to effectively manage provide appropriate support (Coole (Wright6). This was endorsed within the employment difficulties for patients with et al.8). These issues, alongside focus group discussion where low back pain. The most endorsed frustrations about ‘problems with the participants proposed that there should questions for help that had been system’ (complexity of the benefits be a ‘link person’ involved in their care: provided were the following: enabling system, lack of response to applications) someone who understood their chronic patients to be more physically able at make the whole process precarious. pain problem but was also aware of work (36%: 9/25) and providing However, participants were also asked to benefits entitlements (especially in the reassurance about damage (28%: 7/25). make suggestions for ‘service context of concerns about RTW trials) When enquiring what input was still improvements’. The conclusion of these and issues such as employers’ required, the domain for fitness remained discussions was that there should be a expectations of a graded RTW. These about the same (24%: 6/25); although ‘link person’ who could work across the issues are discussed in more detail patients were still on treatment and there chronic pain and vocational/employment later on. was still a potential for this to be services (Wright et al.3), in effect, acting In the first survey, there were four addressed, it may be valuable for the as an advocate for the patient. It was additional comments which related to team to reflect on this feedback. emphasised that the link person should treatment expectations (e.g. symptom However, in terms of requiring understand the medical complexity of the relief or resolution), with three identifying reassurance about damage, this health problems, be able to access notes additional health concerns and one endorsement had dropped to 12% and discuss cases with clinicians, respondent expressing dissatisfaction (3/25). employers and human resource about their doctor. At the 3-month With respect to what input was still departments. Clearly, this would be a follow-up survey, 7/26 comments related required, help to get back to/stay in new way of working and would require to dissatisfaction with their medical care, work (28%: 7/25) and to address specialist training and supervision, and 7/26 provided positive feedback, concerns about financial or litigation especially around issues pertaining to and there were four comments related to issues (24%: 6/25) were the most confidentiality – yet, this could provide a ongoing concerns about their health endorsed responses. These two pivotal role in enhancing the rehabilitation problem. These will be highlighted to the domains had also been identified at the of a cohort of patients with complex clinical teams. first appointment: 45.9% (68/148) and needs. The main theme from the comments 27% (40/148), respectively. Again, this It was also proposed that there could on the first survey focussed on ‘specific would be beyond the skills of a health- be work placements established within employment difficulties’ with two care professional to address, but would the hospital to help build confidence and respondents highlighting specific be in the domain of a vocational advisor. experience in what could feel like a more ‘financial concerns’. Clearly, these would However, as identified in the focus ‘safe’ environment. As there are already be beyond the remit of health-care group, patients raised concerns about schemes across the trust to support professionals to address, but arguably, to ‘negative perceptions’: being people in gaining work experience, this maximise ‘recovery’ from a health ‘unemployable’; being at an may be a viable area to explore and problem, they would need to be dealt ‘employment risk’; or that people with would merit further enquiry. with. Of concern is that only one health problems ‘should not be given a respondent described a positive situation chance’. Paradoxically, the stress of Strengths/weaknesses of the with the workplace. Interestingly, there worrying about these perceptions (and survey evaluation were no employment-focussed therefore potentially working even harder Despite best efforts, there was poor comments on the 3-month survey, with to compensate for them) could, in itself, engagement with the survey process, only three comments relating to ‘financial make it more likely that pain sufferers do although it does seem that the or social concerns’. However, with the go off sick or perform less effectively. respondent sample represented the age fixed-response answers, although 40% These perceptions of patients are also in distribution of the new patient referrals to (10/25) stated that input from the pain line with previous research (Coole the pain team. However, the response team had helped to address their et al.8). rates for both surveys were around 30%, vocational issues, 80% (20/25) indicated Participants expressed frustration that which was recognised as being an that they needed additional support. This job centre workers and health-care acceptable level. Follow-up times were is in concordance with a qualitative study professionals do not have enough originally set at 3 and 6 months. Due to
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poor response rates, it took longer than context of patients’ health problem, and and also act as the patients’ advocate. planned to distribute the questionnaires, yet chronic pain is a complex, and often This was particularly relevant in the and so only 3-month data were acquired. misunderstood condition. Reassuringly, context of patients being keen to explore This meant that none of the respondents there was overall positive feedback ways of returning to work, but having had completed their treatment which regarding patients’ clinical experience, anxieties that they would lose benefits may have affected their view of the indicating that although there may be a should this be unsuccessful. service. shortfall in the level of physical Trialling the employment of a ‘link’ Significant effort was made to ensure rehabilitation for work, patients were person to work across health and that a non-clinical research assistant was being reassured about their structural vocational issues could be part of a involved in the distribution of integrity for work. However, there was research project but would require careful questionnaires and collation of data to frustration around lack of reciprocal planning and support to ensure adequate minimise the risk of bias. Similarly, the attitudes, information and knowledge provision of funding, training and focus groups were run by staff not held by health-care professionals and supervision. It could also be an opportunity involved with participants’ care. vocational advisors, which are required to explore the delivery of an innovative but to support people with complex health integrated model of care designed to and employment needs. In accordance support some of the most complex Conclusion and with previous research, it was proposed patients seen within the pain service. recommendations that this could be addressed by Employment or financial/litigation employing a ‘link’ person who would References not printed but can be difficulties need to be considered in the have the ability to cross these domains obtained from the author by email.
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Informing practice Why not a career in Pain Pain News 11(4) 251 –252 Medicine? © The British Pain Society 2013
Dr Bence Hajdu Frimley Park Hospital [email protected] Dr Mohjir Baloch Frimley Park Hospital Anne Fish Park Hospital
Specialising in Pain Medicine is a potential responders, 3 were core career option for every anaesthetic trainee. trainees. Out of the target The current training consists of four steps: group of 20 ST3-/ST4-level Basic, Intermediate, Higher and Advanced. anaesthetic registrars, 3 were The first two modules are compulsory and ST4s and 17 were ST3s. part of the curriculum, and the latter two In terms of exposure to Pain are optional and for those who wish to Medicine, 17 out of 20 trainees sub-specialise in chronic pain. The had experience in intermediate expectation towards anaesthetic trainees is pain training. Two of the ST4s to be familiar with the treatment of acute and one of the ST3s had pain and have an understanding of issues finished their intermediate pain around chronic pain, and relevant training at the time of the procedures.1 The point in their career survey. One ST4 and 13 ST3s where trainees decide to specialise in had their module in progress. chronic pain often needs to occur at the Three ST3s had no intermediate level of ST3 or ST4 so that provision for the training started at the time. The higher training modules can be put into survey found variable amounts place in years ST5 and above. of experience among the In our region, London and Kent, Surrey a local hospital. The survey consisted of surveyed trainees (Table 1). and Sussex (KSS) Deanery, we have two main parts. In the first part, the The second part of the survey noticed consistently low numbers of exact training level and experience explored career choices. Of the 20 trainees wishing to pursue a career in gained in the field of Pain Medicine were trainees, 9 (45%) have already made a pain management. Advanced pain identified, using multiple-choice decision on their sub-specialty. All 3 training posts are often under-subscribed, questions. This was intended to allot the ST4s and 7 of 17 (35%) ST3s answered and a similar conclusion was drawn by right group of trainees and set the as follows: the UK-wide national pain audit, although context of experience in there does appear to be some regional pain for the second half of variation.2 In the light of this, we aimed to the survey. Then, trainees carry out a small survey to find out what were asked to give free text may be the reasons that junior specialist answers about their career anaesthetic trainees (ST3/ST4) decide choices and the reasons not to pursue pain training. why they decided against A pre-formatted, anonymous, Pain Medicine. scannable survey, consisting of five Of the 29 participants, 23 questions was distributed to a group of completed the survey, ST3-/ST4-level anaesthetic registrars which was a 79% attending a regional cancer study day at compliance rate. Of the 23
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work were the main deterrents. The Table 1. Trainee experience reported reasons given for this were clinics being Finished module Module in progress difficult and unfulfilling, despite the Acute pain rounds 2 – 4 0 – 1 reported overall improvement in general Chronic pain clinics 10 – 20 0 – 10 patient condition in the 70.6% of 2 Theatre lists attended 10 – 30 0 – 15 clinics. Interpersonal skills used in daily Procedures performed 20 – 180 0 – 20 anaesthetic work show a great difference compared to that needed in treating chronic pain, and this seemed On the question of why they have not exposure is engaging in order to entice to be acknowledged by some of the chosen Pain Medicine 2 of 3 (66%) ST4s trainees into this sub-speciality for the juniors and was either deterrent or at and 10 of 17 (58%) ST3s gave a rest of their professional career. The least a recognised weakness. Hence response. There was usually more than National Pain Audit highlighted the further training in the daily dealings with one type of statement as response. The current situation that trainee exposure this patient group, or more widely the responses with their frequencies in to Pain Medicine is lacking, and this chronically ill patient group, could brackets are as follows: contributes to a lack of interest. This increase trainee’s interest in the field, might be bolstered through educational especially techniques related to clinic •• Interested in something else (7); events3 specifically for junior work. The experience trainees get •• Not interested in Pain Medicine, but anaesthetists but also by the during the ST3/ST4 years appears to no other preference (5); introduction of pain teaching in the be crucial in their choice of sub- •• Clinics are difficult/uninteresting/ undergraduate curriculum. speciality. Presentation of the subject unfulfilling (4); There are some uncertainties about might be a reason why trainees did not •• Not enough exposure to Pain the future of the speciality centred find it interesting, despite the Medicine as yet (3); around commissioning. These are being management of pain being an •• Not enough exposure to other addressed by meetings held all around intellectual challenge, requiring work in anaesthetic sub-specialities to the United Kingdom, and many a stimulating, fast developing decide (1); commissioning issues are being dealt multidisciplinary environment, with a •• Doesn’t feel trained in managing with by the implementation of the British good amount of successful treatment personality/psychological issues (1); Pain Society’s (BPS) pain patient options. •• Preference of variety of theatre work pathways.4 Interestingly, in our survey, The field of Pain Medicine is full of of generalists (1). these issues appeared unfamiliar or not a opportunities in the theatre, clinic and matter of concern to the junior group, as laboratory environment, backed by a there was no mention about these in Discussion buzzing scientific and social background, their responses. Although this is a small survey, helpful which makes it a rewarding choice of information was attained from the views career. Hopefully, more trainees in the of these trainees and the importance of Conclusion future will recognise this and choose Pain their exposure to Pain Medicine. It Basically, there have been two groups Medicine as a career. seems that all ST4s, who have attended among trainees: this study day, have already decided on References their sub-specialisation and so did •• Decided against pain and may or 1. Curriculum for a CCT in anaesthetics. Available online at http://www.rcoa.ac.uk/system/files/TRG- seven of the ST3s. Although the may not have developed a different CU-CCTAnaes2010_3.pdf number of participants is small, this interest; 2. National Pain Audit. Available online at http://www. might give a suggestion of the •• Decided for pain or at least remained britishpainsociety.org/members_articles_ npa_2012.pdf importance of the ST3 year in the open about it, calling for further 3. Balasubramanian S, and Gupta S. Pain education training programme. The ST3 year is experience and training. and the Faculty of Pain Medicine. Pain News 2013; often the year in which trainees have 11(3): 148. 4. Nicolaou A. Pain patient pathways and their first experience of chronic pain Among those who completely refused commissioning roadshows – Feedback and work. It is therefore important that this Pain Medicine, disinterest and clinic evaluation. Pain News 2013; 11(3): 149–50.
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Informing practice Dealing with DNAs Pain News 11(4) 253 –254 © The British Pain Society 2013 Chaitanya Kumar Vasappa Advanced Pain Trainee, Birmingham School of Anaesthesia [email protected]
National Health Service (NHS) has been £600 million in the year 2007/20083 and longer needed, childcare and so on. going through some tough times. Among probably cost £800 million in Some of the hospital factors7 that can others, a difficult financial situation is 2011/2012.4 This has prompted an increase DNA rate are difficulty in probably on top of the list. There is a real outcry in the media with one report cancelling appointments, short need for us to look into every area of our suggesting that the money lost was notification, poorly designed practice to make it more efficient so that equivalent to 1% of health budget, and appointment letter and lack of we provide optimal care to our patients could have covered the cost of a new organisation of clinics. and make sure that the money spent is hospital or paid for 115,000 hip maximally utilised. Pain clinic replacements or 110,000 heart bypass What could be done to reduce appointments like any other outpatient operations.4 DNAs appointments are an important part of The vacant slot in appointments Hospitals can use several strategies to our service. We have a duty to audit our obviously means delayed care for people bring down the DNAs. Some of which pain clinic attendances so that we who could have been offered those slots. are7 recognise any problems and explore the This will lead to longer waiting lists and options to help and improve our pose problems for hospitals in meeting •• Making appointments only when it is performance. the 18-week referral to treatment target. necessary; One of the problems that we face in Doctors’ and nurses’ time in clinic is •• Good and clear communication with our outpatient clinics is of missed naturally wasted. It also puts pressure on patients; appointments or Did Not Attends (DNAs). administrative staff if they have to rebook •• Easy to cancel appointments; The Department of Health report1 for those patients for another appointment. •• Partial booking;9 2011/2012 showed that in England, for This may lead to frustration among •• Choose and book; around 53 million appointments made, hospital staff. GPs will also have to bear •• Patient reminders; 5.5 million Did Not Attend, making the the brunt of re-referring. A hospital/trust •• Education. percentage of DNAs around 10%. This with high DNA rate would lose some of rate was different for different regions: its efficiency, and this may impact its reputation and ability to provide good Patient reminders England 10.31% service. Using some kind of patient reminder is an easy and cost-effective way of North East 10.01% reducing DNAs. A letter could be sent East Midlands 9.16% Reasons for DNAs one week before the appointment. There have been some studies to look Although sending letter may not be very West Midlands 10.63% into the reasons why patients do not effective, it is probably better than London 14.18% attend their appointments. Young males nothing. Several hospitals have used South West 7.51% are more likely to miss an appointment telephone calls as reminders. These calls than older patients. Patients who are could just be a reminder or an interactive There was a reduction of DNAs by socially deprived have higher rate of service which allows patients to confirm, 4 250,000, but still more than acceptable. DNA. Few studies and surveys done in cancel or rebook appointments. This has Some regions are still witnessing a rise.2 the United Kingdom list more practical been shown to reduce DNA rate reasons for DNA.5–8 Simply forgetting significantly.10–13 Mobile phone text their appointment was on top of the list. messages may be one of the simple, Problems caused by DNAs Other factors that increase DNA are effective and cheaper ways of reminding The financial loss to NHS could be huge. clerical errors, time of appointment, patients of their appointments.14 A It is estimated that the loss was around distance to travel, appointment no Cochrane review8 on mobile phone
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messaging reminders concluded that vulnerable and sick patients may be 6. Neal RD , Hussain-Gambles M , Allgar VL , et al . text messaging reminders increase affected. 18 It may also be difficult practically Reasons for and consequences of missed appointments in general practice in the UK: attendance at health-care appointments. to implement any such measures. Questionnaire survey and prospective review of They are better than postal reminders medical records. BMC Family Practice 2005 ; 6 : 47. and as good as phone reminders. The DOI: 10.1186/1471-2296-6-47 . Available online at Summary http://www.biomedcentral.com/1471-2296/6/47 costs per attendance of text messaging The rate of DNA in outpatient clinics in 7. Available online at http://www.institute.nhs.uk/ are lower compared to phone call quality_and_service_improvement_tools/quality_ NHS continues to be a problem. There reminders, making them more cost and_service_improvement_tools/dnas_-_reducing_ are several reasons for patients to miss did_not_attends.html effective. One of the examples of an appointment. Forgetting an 8. Available online at http://onlinelibrary.wiley.com/ successful implementation of patient doi/10.1002/14651858.CD007458.pub2/abstract appointment is a common reason for reminder systems is in Portsmouth 9. Available online at http://www.whittington.nhs.uk/ DNA. This could be tackled by using document.ashx?id=2005 Hospitals NHS Trust. By using simple and cost-effective measures like 10. Available online at http://www.uhsm.nhs.uk/news/ automated texting and voice messaging, Pages/UHSMtacklescostlymissedappointments text messaging services. Educating they have reduced the DNA rate by over .aspx patients regarding importance of not 11. Available online at http://www.cht.nhs.uk/news/ 60%. 14 There are systems available in the missing an appointment is probably more news-item/article/new-service-to-cut-missed- market that could be integrated into appointments effective and practical than any attempts existing NHS administrative systems to 12. Available online at http://www.epsom-sthelier.nhs. uk/news/news-archive/2013/august-2013/missed- 15 to impose penalty on those who DNA. generate patient reminders. hospital-appointments-down-by-a-quarter-saving- 665k/ References 13. Available online at http://www.midyorks.nhs.uk/ Patient education 1. Available online at https://www.gov.uk/government/ main.cfm?type=APPOINTMENTREMINDER Bringing awareness among patients news/hospitals-and-patients-urged-to-take-action- 14. Available online at http://www.porthosp.nhs.uk/ on-missed-appointments reduction-in-did-not-attend-appointments.htm about the importance of keeping or 2. Available online at http://www.bbc.co.uk/news/ 15. Available online at www.integria.co.uk/ cancelling their appointments will uk-scotland-23646939 RedDNAJul09.pdf certainly reduce DNAs. There have been 3. Available online at http://www.drfosterhealth.co.uk/ 16. Available online at http://www.nhs.uk/ features/outpatient-appointment-no-shows.aspx 16 , 17 aboutNHSChoices/professionals/ several campaigns towards this but 4. Available online at http://www.express.co.uk/news/ healthandcareprofessionals/your-pages/ more needs to be done. uk/295726/Missed-appointments-cost-NHS- Documents/110702_Posters_Final_BWHR%202. 800m-a-year pdf 5. Murdock A , Rodgers C , Lindsay H , et al . Why do 17. Available online at http://www.northeast.nhs.uk/_ Penalty patients not keep their appointments? Prospective assets/media/pdf/NHS_DNAleaflet.pdf study in a gastroenterology outpatient clinic . 18. Available online at http://www.pulsetoday.co.uk/ Penalising patients who miss their Journal of the Royal Society of Medicine 2002 ; 95 : comment/opinion/should-gps-charge-for- appointments is a contentious issue as 284 – 6 . dnas-no/20000749.article
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254 Pain News l DecemberHalf 2013 Vol 11page No 4 Horizontal PAN510842.indd 254 120mmx180mm 08/11/2013 4:29:50 PM PAN11410.1177/2050449713511369Informing practiceLumbar epidural adhesiolysis by Racz catheter technique 5113692013
Informing practice Lumbar epidural adhesiolysis by Pain News 11(4) 255 –258 Racz catheter technique © The British Pain Society 2013
Dr Devendra Tilak Clinical Fellow [email protected] Dr Riaz Khan Khyshzai Consultant in Pain Medicine Dr Anthony Ordman Consultant in Pain Medicine, The Royal Free London NHS Foundation Trust
Neuropathic pain secondary to the space at the site of adhesions along the numbness and possibly, bladder and presence of lumbar epidural adhesions is exiting nerve root. Local anaesthetics bowel difficulties.3,4 a common problem presenting in the and steroids are delivered to the target This syndrome is not an uncommon pain clinic. Lumbar back and/or leg pain area, while adhesiolysis is performed with problem, and one recent UK survey from epidural adhesions may follow hypertonic (10%) or normal (0.9%) saline, quotes the incidence at around 10%– spinal decompression surgery, but may with or without hyaluronidase. PLEA is 40%.1 This is commonly termed as ‘failed also be the result of annular disc tear or not carried out in majority of pain clinics back surgery syndrome’ (FBSS), but in infections such as bacterial discitis. Filmy, in the United Kingdom, and at present, our view, the term ‘FBSS’ has negative collagenous adhesions develop in the only a few patients have access to this connotations, which can create epidural space, resulting in tethering of minimally invasive and potentially useful confusion in the minds of patients and nerves, increased neural tension and intervention.1 clinicians alike, implying that surgery was neural strangulation. We suggest that Racz PLEA may be somehow badly carried out, adding to Interventional techniques, such as carried out safely and effectively in most the burden of uncertainty that the patient epidural and selective nerve root steroid pain clinics in the United Kingdom where already carries. For this reason, we prefer injection, are commonly used, alongside intervention treatment is carried out, to use the term ‘post lumbar surgery nerve pain medications such as the given the relative ease of acquiring the syndrome’ (PLSS), now commonly used tricyclics and anti-epileptics. Opioids are necessary skills by observation and one- in North America. often added, even at high doses. to-one teaching, its safety and efficacy Patients with PLSS have a poor quality Significant pain may persist despite such and low start-up costs. of life and secondary psychological prescribing, and patients are often beset problems and are therefore frequent users with side-effects. of the health service. Managing persistent With this in mind, we have recently Clinical background pain in this group of patients is often adopted Racz’s minimally invasive Persistent low back and radicular leg challenging. Secondary open surgery for technique of percutaneous lumbar pain caused by intervertebral disc removal of epidural scarring also has epidural adhesiolysis (PLEA), which can herniation, spinal stenosis and limited success with long-term benefit be performed via caudal, inter-laminar or spondylolisthesis is the most common seen only in a small number of patients.5,6 transforaminal routes. We have reason for lumbar spinal surgery. Epidural steroid injection and selective concentrated on the caudal epidural However, chronic back and/or leg pain nerve root blocks are the most common route, which we discuss here. For us, may start after technically successful interventions performed for PLSS. PLEA has proven to be a useful spinal surgery, often after an interval, and Epidural steroid injections do not prevent technique, alongside the multidisciplinary persist beyond 6–12 months. Extent of formation of epidural adhesions7 and only pain management of patients with peridural scarring is directly related to provide a short-term improvement in pain lumbar epidural adhesions. recurrence of radicular pain post lumbar and function for up to 2 weeks.4 PLEA is a technique that was laminectomy.2 Symptoms related to Epidural adhesion formation is developed to mechanically break up epidural adhesions commonly include common after lumbar surgery, and an epidural adhesions with the use of back and/or leg pain, while some important cause of PLSS, and should be soft-tipped wire-bound catheter, placed patients also experience weakness and considered, alongside differential commonly in the ventro-lateral epidural sensory or muscle spasms in the limbs, diagnoses such as recurrent disc
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herniation, spinal stenosis, ligamentous Racz catheter technique With this in mind, we do not currently disease, facet and sacroiliac joint PLEA was developed by Dr Gabor Racz use hypertonic saline for PLEA. Catheter disease, adjacent segment disease and and Houlbec in 1989 in Boston, as a shearing has been reported. The catheter so on which should all be excluded.2 3-day procedure, which was then may shear, while advancing the R.K.™ Epidural fibrosis may also develop modified by Manchikanti et al.8 to a needle, particularly if the stylet is not secondary to annular tear and leak of 1-day procedure. Manchikanti et al. have inserted fully. There have been case nuclear material, disc inflammation or not found a significant difference when reports of transient radicular neurological infection and the presence of blood in 3-day epidurolysis procedure was deficit after PLEA. No clear causes have the epidural space.8 Epidural adhesions compared to 2-day and 1-day been identified. There are case reports of may also contribute to the pain of procedures.8,10 The same group also spinal infection, with patients developing degenerative spinal canal stenosis in an found, more than 50% pain reduction in epidural abscess and meningitis. increasing ageing population, especially 90% and 72% of the patients at 3 and Systemic steroid effect are well known, when simple epidural steroid injection 12 months, having three to four 1-day we are especially worried about raised has not sufficed. Micro-bleeds are PLEA procedures over a 12-month blood sugar levels and adrenal/ thought to occur in the extensive venous period, compared with 35% and 12% of hypothalamic–pituitary–adrenal (HPA) epidural plexuses caused due to the patients in caudal epidural group, having suppression. A study done here at the encroachment by surrounding structures 2–3 caudal epidural steroid injections Royal Free, had demonstrated high levels such as discs, facet joints and ligaments. during the same period. The PLEA group of triamcinolone, sufficient enough to Patients with epidural scarring are also had an average 40% improvement cause HPA suppression, in the blood up three times more likely to develop in function at 12 months, compared to to 9 days post transforaminal epidurals.12 recurrent radicular pain.2 Nerve roots 13% in the caudal epidural group.4 No cases of epidural haematoma have encased in such adhesions may be Veihelmann et al.11 compared 1-day been reported. There are no case reports tethered by them, resulting in increased adhesiolysis to physiotherapy. The of serious neurological deficit after neural tension preventing neural glide physiotherapy group showed no adhesiolysis, including paralysis, weakness during limb and spinal movement significant change in leg Visual Analogue or bladder and bowel dysfunction.13 (positive ‘slump test’, and femoral and Scale (VAS) at 3, 6 and 12 months, while sciatic stretch tests). There may also be in the adhesiolysis group, VAS reduced strangulation of the nerve root: restriction from 7.2 to 2.4 at 3 months and stayed Our method and audit of of arterial supply and venous return, and at 2.8, at 12 months. Hypertonic saline is outcomes also reduction in nutrient and axoplasmic commonly used for adhesiolysis and One of us (R.K.K.) was fortunate enough transport, all of which may increase neurolysis during PLEA procedures, and to have been taught this procedure by Dr neural irritability. Manchikanti et al. showed more than Gabor Racz, and incorporated Racz Repeat magnetic resonance imaging 50% pain reduction in 72% patients in a PLEA into his practice here at the Royal (MRI) is commonly performed in this hypertonic saline group compared with Free, as an additional interventional group of patients to evaluate recurrent 60% in a normal saline group. The technique, for managing patients with problems after surgery.1 However, non- duration of pain reduction was also suspected epidural adhesions, who have contrast MRI scan may fail to longer: 3.8 versus 2.8 months.8 failed to respond to standard treatments. demonstrate epidural scarring. We implement the modified, 1-day Gadolinium with diethylene triamine protocol as described by Manchikanti penta-acetic acid (Gd-DTPA)-enhanced Possible complications of PLEA and others, which R.K.K. has taught us MRI scans may be useful in diagnosing Dural puncture is the most common here. We have audited our current epidural adhesions and differentiating complication reported, at around 2%.4,11 practice of PLEA procedures performed them from recurrent disc herniation.9 One consequence of dural puncture is over 18 months between January 2011 However, the filmy adhesions discussed that local anaesthetic or, worse, and July 2012. Data were collected here may not become apparent on even hypertonic saline could enter the retrospectively from patients’ notes, the most detailed of MRI. Instead, they subarachnoid space, resulting in a spinal outpatient clinic letters and telephone may be demonstrated by radio contrast block or neural damage, respectively. reviews. We documented percentage epidurography carried out under Arachnoiditis following epidural reduction in pain, improvement in fluoroscopy, as a prelude to the Racz adhesiolysis with hypertonic saline has function following PLEA, as reported by catheter procedure, with adhesions been attributed to unrecognised the patients, and sought information identified as filling defects.6 subarachnoid entry of hypertonic saline. regarding adverse effects.
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Procedure They are then encouraged to move Figure 2. The X-rays shows a filling All procedures are performed in the freely and to stretch the limbs, and flex and defect. One can also see a vascular operating room, under appropriate extend the spine, and if possible attend for runoff of contrast aseptic conditions, using fluoroscopy. physiotherapy, hoping to further stretch We established intravenous access, and break down epidural adhesions. giving conscious sedation as required. We applied local anaesthetic to the Our results caudal injection site. The epidural space was accessed via caudal route (sacral Graph 1. Age distribution hiatus) using a specially designed 16G RX Coudé epidural needle (Epimed) under fluoroscopic guidance. Lumbar epidurogram was carried out using 2–5 mL of iohexol contrast-medium (Omnipaque-240), with adhesions identified as filling defects along course of nerve roots. Additionally, absence of intravascular, subarachnoid and subdural spread of contrast was confirmed. Figure 3. Post-adhesiolysis contrast The Racz catheter, a spring-guided spread outlining of S1 nerve root reinforced catheter, is passed through 15 men and 8 women were treated the Coudé needle to the site of filling with percutaneous lumbar epidural defect or the site of patient’s pathology adhesiolysis (PLEA); as determined by the dermatomal level Age distribution is shown in (Graph 1); of the patient’s symptoms, and by investigation (MRI) findings (Figure 1). 23 patients had 27 procedures; Following placement of the catheter, 20 of 23 patients had previous mechanical adhesiolysis is carried out surgical spinal decompression. by movement of the catheter, and by injecting small aliquots of 0.9% saline with or without hyaluronidase. Graph 2. Duration and quality of Following adhesiolysis, a repeat pain reduction epidurogram is carried out, successful
adhesiolysis being confirmed by the Figure 1. Racz catheter in the spread of contrast material along the sacral epidural space nerve root (Figures 2 and 3), with filling in of the ventro-lateral epidural space. In all, 3–6 mL of mixture of 1% lidocaine with triamcinolone 40 mg is delivered at the target area. Of the 27 procedures performed, Following completion of the procedure, 20 procedures (74%) were beneficial; needle and catheter are removed, and a bio-occlusive dressing is placed. The 44.4% of the patients had > 50% catheter is checked for any damage and reduction in pain (Graph 2); for intactness. 74% patients had some benefit (pain Patients are observed in the recovery reduction), while in nearly 60% room, and discharged home when patients, the benefit lasted from recovered, with appropriate aftercare 2 to 5 months (Graph 2). instructions and contact information.
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epidurolysis in terms of capital outlay and neurolysis in treatment of chronic low back pain: a Graph 3. Post-adhesiolysis the ease of acquisition of the necessary randomized, double-blind trial. Pain Physician changes in activity levels 2004; 7(2): 177–86. clinical skills. We are not recommending 9. Fan YF, Chong VF, and Tan SK. Failed back surgery it as a first-line treatment, and we syndrome: differentiating epidural fibrosis and strongly feel it should part of the recurrent disc prolapse with Gd-DTPA enhanced MRI. Singapore Medical Journal 1995; 36(2): 153–6. multimodal approach. 10. Racz GB, and Holubec JT. Lysis of adhesions in the epidural space. In: GB Racz (ed.) Technique of Neurolysis. Boston, MA: Kluwer Academic References Publishers, 1989, pp. 57–72. 1. Tharmanathan P, Adamson J, Ashby R, et al. 11. Veihelmann A, Devens C, Trouillier H, et al. Epidural Diagnosis and treatment of failed back surgery neuroplasty versus physiotherapy to relieve pain in syndrome in the UK: mapping of practice using a patients with sciatica: a prospective randomized cross-sectional survey. British Journal of Pain blinded clinical trial. Journal of Orthopaedic 2012; 6: 142–52. Science 2006; 11(4): 365–9. 2. Ross JS, Robertson JT, Frederickson RC, et al. 12. Morgan-Rowe L, Rai B, Morgan M, et al. 66.7% patients reported improvement Association between peridural scar and recurrent Triamcinolone in Interventional Pain Management in function; radicular pain after lumbar discectomy: magnetic Procedures is Detectable in the Systemic resonance evaluation. Neurosurgery 1996; 38(4): Circulation. London: Pain Management Service, Only one patient reported worsening 855–63. Royal Free Hospital. of pain by 2 points (20%), and 3. Trescot AM, Chopra P, and Abdi S. Systematic 13. Helm Ii S, Benyamin RM, Chopra P, et al. reduced activity levels (Graph 3); review of effectiveness and complications of Percutaneous adhesiolysis in the management of adhesiolysis in management of chronic spinal pain: chronic low back pain in post lumbar surgery There were no other complications an update. Pain Physician 2007; 10: 129–46. syndrome and spinal stenosis: a systematic review. reported. 4. Manchikanti L, Cash KA, McManus CD, et al. The Pain Physician 2012; 15: E435–62. preliminary results of a comparative effectiveness 14. Talu GK, and Erdine S. Complications of epidural evaluation of adhesiolysis and caudal epidural neuroplasty: a retrospective evaluation. injections in managing chronic low back pain Neuromodulation 2003; 6(4): 237–47. Conclusion secondary to spinal stenosis: a randomized, 15. Gerdesmeyer L. Neurolysis of adhesions: updates. There is fairly good evidence, that Racz equivalence controlled trial. Pain Physician 2009; In: Pain practice conference: 6th World congress, catheter PLEA is a safe and effective 12(6): E341–54. Miami, FL, 4–6 February 2012. 5. North RB, Campbell JN, James CS, et al. Failed back 16. Park CH, Lee SH, and Jung JY. Dural sac cross- intervention in relieving low back and leg surgery syndrome: 5-year follow-up in 102 patients sectional area does not correlate with efficacy of pain in patients with PLSS, when more undergoing repeated operation. Neurosurgery 1991; percutaneous. Adhesiolysis in single level lumbar simple approaches have failed. The 28(5): 685–90; discussion 690–1. spinal stenosis. Pain Physician 2011; 14: 377–82. 6. Singh V, and Manchikanti L. Percutaneous lysis of 17. Manchikanti L, Pakanati RR, Bakhit CE, et al. Role procedure may need to be carried out lumbar epidural adhesions and hypertonic saline of Adhesiolysis and Hypertonic Saline Neurolysis in repeatedly three or four times for maximum neurolysis. In: MV Boswell, and BE Cole (eds) Management of Low Back Pain: Evaluation of effect. PLEA provides relief to patients who Weiner’s Pain Management. Boca Raton, FL: CRC Modification of Racz Protocol. Paducah, KY: Pain Press, pp. 1023–41. Management Centre of Paducah, 1999. have no other option other than implantable 7. Häckel M, Masopust V, Bojar M, et al. The epidural 18. Manchikanti L, Singh V, Cash KA, et al. A neuromodulation devices, or secondary steroids in the prevention of epidural fibrosis: MRI comparative effectiveness evaluation of surgery, which is unlikely to be beneficial.3,13 and clinical findings. Neuro Endocrinology Letters percutaneous adhesiolysis and epidural steroid 2009; 30(1): 51–5. injections in managing lumbar post surgery We feel that Racz catheter PLEA has 8. Manchikanti L, Rivera JJ, Pampati V, et al. One day syndrome: a randomized, equivalence controlled certain advantages over epiduroscopic lumbar epidural adhesiolysis and hypertonic saline trial. Pain Physician 2009; 12(6): E355–68.
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PAN511369.indd 258 08/11/2013 4:30:29 PM PAN11410.1177/2050449713511370Informing practiceThe effect of capsaicin 8% patch in patients with peripheral neuropathic pain following surgery. A case report study 5113702013
Informing practice The effect of capsaicin 8% patch Pain News 11(4) 259 –261 in patients with peripheral © The British Pain Society 2013 neuropathic pain following surgery. A case report study
P di Vadi Chronic Pain Service, University Hospital Lewisham, London [email protected] M Pedro Chronic Pain Service, University Hospital Lewisham, London J Sheppard Chronic Pain Service, University Hospital Lewisham, London R Dutta Department of Pain Management, Ashford and St Peter’s Hospitals NHS Foundation Trust, Surrey
Chronic pain of moderate to severe approximately, according to a systematic denervation of the peripheral terminal of intensity occurs in 19% of adult review of clinical trials.6 The higher TRPV1-expressing neurons in the Europeans, seriously affecting the quality concentration of topical capsaicin epidermis in a highly selective manner, of their social and working lives1 and is a resulted in higher levels of pain relief than resulting in hypoalgesia.9 It also reduces substantial health-care problem. the lower concentrations of capsaicin,6 sensitivity to heat and sharp pain stimuli.9 Persistent pain following surgery has although the benefit was not statistically Over a few months after the application, been extensively investigated to find out significant. It is important to note that a re-innervation of the treated area with any predictive risk factors and its possible patients achieving pain reliefs also TRPV1 takes place and, consequently, prevention.2,3 The prevalence of improved their quality of life, sleep, the pain comes back.9 prolonged pain is experienced by many depression and fatigue.6 The efficacy of Topical capsaicin has been found to patients (10%–50%), with an extreme capsaicin patch 8% is similar to other be effective in the management of painful variability between studies, according to therapies used for chronic pain and is diabetic neuropathy, often in conjunction comprehensive review of the French and suggested to be used when other with antiepileptics and English medical literature from 1998 to available therapies have failed;7 it is one antidepressants.10,11 In general, 2013.4 The incidence of severe persistent of the few neuropathic pain treatments combination therapy, rather than localised pain after surgery reduces to which have been successfully translated monotherapy, has shown more positive 5%–10% of patients,4 but was found to from basic bench research to human response in the management of be present in approximately 30% of treatment.8 It is a highly selective agonist neuropathic pain.12 No information is patients one year after knee arthroscopy.5 for the transient receptor potential currently available in literature about the Topical cream with capsaicin is used to channel vanilloid-receptor type 1 effectiveness of topical treatment in treat peripheral neuropathic pain. (TRPV1), which is an ion channel persistent localised pain following Following application to the skin, receptor complex found on central and surgery. capsaicin causes local desensitisation peripheral terminals of nociceptive after repeated applications. The high- primary sensory neurons.9 When concentration (8%) capsaicin patch was capsaicin is applied locally, it initially Table 1. Demographic data developed to increase the amount of the enhances and stimulates the TRPV1- compound delivered and is given as a expressing cutaneous nociceptors, • All patient treated: 23 single application to the affected area. which may be associated with painful • 12 female, 11 male • Average age 47.5 (24-86) The benefit lasts for 12 weeks sensation. This is followed by
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Table 2. Areas of neuropathic scar pain Table 3. Mean and standard deviation for VAS Patient Sex Age Location of Pain Mean VAS SD VAS 1 Female 27 Left elbow 2 Female 57 Left leg Baseline 8.36 0.71 3 Female 65 Left mid thoracic back 1 month 6.04 1.58 3 months 6.86 1.39 4 Female 86 Central lower abdominal (post-hysterectomy) 5 Male 41 Left ankle 6 Male 59 Right foot VAS: Visual Analogue Scale; SD: standard 7 Female 51 Right lower abdominal (post-hernia) deviation. 8 Female 47 Right upper thoracic back 9 Male 38 Right leg pain dropped out, and data were not available 10 Male 45 Left breast (post-mastectomy) at follow-up. The mean numeric rate 11 Female 36 Right foot score (0–10) of the 22 patients 12 Male 53 Right knee completing the study was 8.36 at 13 Male 42 Left foot baseline, 6.04 at 1-month follow-up and 14 Female 41 Right hand/wrist 6.86 at 3-month follow-up. The average 15 Female 68 Left pelvis degree of VAS improvement was 2.32 at 16 Male 24 Left arm 1-month follow-up and 1.50 at the 17 Male 29 Right ankle and foot 3-month follow-up (Table 3 and Figure 3). 18 Female 35 Left foot The mean ± standard deviation VAS for 19 Female 41 Left hand/wrist 22 patients in the treatment group 20 Female 29 Left back scar changed from 8.36 ± 0.71 at the 21 Male 74 Right foot beginning of treatment to 6.04 ± 1.58 at 22 Male 50 Abdominal scar 1 month and to 6.86 ± 1.39 at 3 months 23 Male 56 Left leg scar (Table 3 and Figure 3). Among the patients who did improve, four reported >50% pain relief at 1-month follow-up Methods follow-up, a higher number of patients and one at 3-month follow-up. No side We treated 23 consecutive patients (16) reported some to very good effects or serious adverse reactions were suffering from localised chronic improvement compared to the 3-month reported. neuropathic pain (more than 6 months) follow-up (Figures 1 and 2). One patient following surgery (Table 1) by applying capsaicin patch 8% accordingly with the agreed methodology over the painful Figure 1. Individual patient pain relief at 1- and 3-month follow-up area of the skin.7 They were 12 female and 11 male patients, and the average Individual pain relief age was 47.5 years (Table 2). The pain 12 score was measured by the Visual Analogue Scale (VAS) (0–10) at baseline, 10 1-month follow-up and at 3-month 8 follow-up. One patient was lost to baseline follow-up, and hence, the study was V 6 concluded with 22 patients. A 1 months S 4 3 months
Results 2 A total of 11 patients reported some to 0
very good improvement at the 3-month 1 2 3 4 5 6 7 8 9 pt pt pt pt pt pt pt pt pt
follow-up, and 11 reported insignificant pt10 pt11 pt12 pt13 pt14 pt15 pt16 pt17 pt18 pt19 pt20 pt21 pt22 or no improvement. At the 1-month
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this. Importantly, no side effects were Figure 2. Outcome at 1- and 3-month follow-up reported, apart from temporary localised erythema and hyperaesthesia Response to Capsaicin patch in few patients, which lasted up to 3 All paents (22) hours and did not require any specific 14 therapy. We believe that a randomised 12 control study should be organised in order to confirm these preliminary 10 data. 8 1 month References 6 3 months 1. Breivik H, Collett B, Ventafridda V, et al. Survey of chronic pain in Europe: prevalence, impact on daily 4 life, and treatment. European Journal of Pain 2006; 10: 287–333. 2 2. Kehlet H, Jemsen TS, and Woolf CJ. Persistent 0 postsurgical pain: risk factors and prevention. Lancet 2006; 367: 1618–25. >50% improvement20-50% improvementNo improvement 3. Perkins FM, and Kehlet H. Chronic pain as an outcome of surgery: a retrospective study. Anesthesiology 2000; 93: 1123–33. 4. Martinez V, Baudic V, and Fletche D. Chronic post Figure 3. Mean and standard deviation of pain scores at baseline, 1 month surgical pain. Annales françaises d’anesthèsie et de rèanimation 2013; 32(6): 422–35. and 3 months 5. Rosseland A, Solheim N, and Stubhaug A. Pain and disability 1 year after knee arthroscopic procedures. Acta Anaesthesiologica Scandinavica VAS 2008; 52: 332–7. 10 6. Derry S, Sven-Rice A, Cole T, et al. Topical capsaicin (high concentration) for chronic neuropathic pain in adults. The Cochrane 8 Database Systematic Reviews 2013; 2: CD007393. 7. Irving GA, Backonja MM, Dunteman E, et al. A 6 multicenter randomized, double-blind, controlled study of NGX-4010, a high-concentration 4 VAS capsaicin patch, for the treatment of postherpetic neuralgia. Pain Medicine 2011; 12(1): 99–109. 8. Backonja MM. Neuropathic pain therapy: from 2 bench to bedside. Seminars in Neurology 2012; 32(3): 264–8. 9. Haanpää M, and Treede RD. Capsaicin for 0 neuropathic pain: linking traditional medicine and Baseline1 month3 months molecular biology. European Neurology 2012; 68(5): 264–75. 10. Bril V. Treatments for diabetic neuropathy. Journal of the Peripheral Nervous System 2012; 17 (Suppl. 2): 22–7. 11. Spallone V, Lacerenza M, Rossi A, et al. Painful Conclusion surgery showed a beneficial effect in diabetic polyneuropathy: approach to diagnosis In our prospective study of 23 half of the patients treated; however, and management. The Clinical Journal of Pain consecutive patients, the application of the effect was shorter than expected, 2012; 28(8): 726–43. 12. Vorobeychik Y, Gordin V, Mao J, et al. Combination capsaicin patch 8% as a treatment for reaching the best results at 1 month therapy for neuropathic pain: a review of current localised neuropathic pain following with the benefit partially fading after evidence. CNS Drugs 2011; 25(12): 1023–34.
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PAN511370.indd 261 08/11/2013 4:31:15 PM PAN11410.1177/2050449713511376Informing practiceAssessment of outcomes after interventions – the Glasgow story 5113762013
Informing practice Assessment of outcomes after Pain News 11(4) 262 –264 interventions – the Glasgow © The British Pain Society 2013 story
Dr Clare Bridgestock Consultant in Anaesthesia and Pain Medicine, New Victoria Hospital, Glasgow [email protected]
Chronic pain is a common condition, Assessment of outcomes post. Non-responders were contacted by costly to society and with often A pilot project to record patient telephone at 10 weeks as a reminder. A significant effects on physical function, outcomes after interventional pain further short form recorded how easy the mental health and daily life. For a procedures was trialled in Glasgow in questionnaire was to complete, whether proportion of patients, an interventional 2010. A paper-based questionnaire was all questions were understandable and pain procedure may be appropriate as developed by members of the multi- asked for suggestions to improve the part of the overall management plan for disciplinary team, including medical, questionnaire. Results of the pilot project their chronic pain. Only rarely would this nursing and psychology staff. The pilot were analysed, and our current outcome be the sole therapy; more usually, these project included 50 patients who were audit form was developed (Figure 1). procedures are performed as part of a asked to complete the questionnaire at 8 Since summer 2011, all patients multi-modal care plan, aiming towards weeks post procedure and return it by attending interventional pain procedures some reduction in pain scores but also improvement in physical function, mood, sleep and quality of life. Figure 1. Glasgow chronic pain management service From a patient perspective, it is essential to monitor the outcomes of performed procedures to ensure that we are delivering effective therapies. Clinicians are also required to record outcomes of practical procedures as part of the appraisal process. Focusing resources on those therapies which are most effective is essential if we are to deliver a cost-effective service in the context of a continuously evolving health service, both locally and nationally. A survey published in the recent edition of Pain News investigated the process for follow-up of patients after injection.1 They concluded a marked difference in follow-up practice, in time to follow-up, clinician performing follow-up and outcomes recorded.
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in either treatment room or theatre sessions across National Health Service Figure 2. Procedures performed Figure 3. Percentage of pain relief (NHS) Greater Glasgow and Clyde have after intervention been asked to complete an outcome audit form. Currently, procedures are performed in three hospitals within the trust, all by medical staff. At the time of procedure, each patient is given a standard A4 form which has been partially completed with simple demographic information, a note of procedure and date performed and the name of both the referring and operator clinician. An addressed envelope is provided, and the patient is requested to return the form, by post, 8 weeks post Figure 4. Duration of pain relief intervention. The majority of patients do after intervention not have any further medical follow-up arranged until this outcome form is returned, and there is no system in place for ‘chasing up’ forms not returned. The form, as shown in Figure 1, asks the patient to record the effect of their interventional pain procedure on a number of factors, including proportion and duration of pain relief, sleep, quality of life, mobility and medication use. The patient is also asked about the extent of side effects, with a free text area to comment on these, and whether they feel the procedure was beneficial enough to repeat. clinicians, and 65% of patients were Those gaining a reduction in pain relief Upon return, the questionnaire is female. Figure 2 shows the variety of of >30%, for over 4 weeks, are reviewed by the referring clinician with a procedures performed, the most considered to have a positive response decision made as to whether to offer common being sacroiliac joint injection, to intervention. On these criteria, 42% of further interventional procedures and lumbar facet joint injection, caudal our sample can be defined as whether to arrange follow-up. Forms are epidural injection, trigger point injection ‘responders’. In this group of responders, then collated and stored separately from and lumbar nerve root block, in total 48% also reduced their analgesic use. patient notes, with some clinicians accounting for 70% of all procedures. Side effects were recorded by 25% of all choosing to add a note to the patient Considering degree of pain relief, 58% patients, most commonly pain in the area record regarding outcome. Outcome reported greater than 30% reduction in of injection. In this sample, 55% of data are entered onto the Outcomes pain and 28% of patients reported patients were offered a repeat procedure. Database, running on Microsoft Access, greater than 60% reduction in pain by several clinicians. (Figure 3). Duration of effect was greater Changes in practice Data, from the Outcomes Database, than 4 weeks for 47% of patients, with Since the original data analysis, was analysed from 1 August 2011 to 31 21% still gaining effect at the 8 week considering our first full year of outcome July 2012, representing our first year of follow-up (Figure 4). Sleep was noted to recordings, we have made some small data collection. In all, 836 completed be improved by 36% of responders, and changes to practice. Within NHS Greater questionnaires, from a total of 1,390 29% stated an improvement in their Glasgow and Clyde, we now work performed procedures, were analysed, mobility. Perhaps the most important paper-light and use only an electronic representing a return rate of 60%. marker, 40% stated an improvement in patient record accessed via a clinical Procedures were performed by 14 their quality of life. portal. When outcome forms are
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returned, these are scanned and added repeat, as repeat procedures are patients, delivering a cohesive approach to the patient file prior to data being more likely to be responders, to their management. entered to the database. This can be therefore positively skewing data; A possible interim suggestion is to first useful when comparing effect of •• Modification to form to include average ensure all patients attend a pain procedures which are performed on a pain score at time of intervention and education session prior to an number of occasions. We are also now again at time of return. This can interventional procedure, then to perform using these forms to record outcomes quickly be further assessed at other a top-up session immediately after from acupuncture, which was previously appointments within the pain service intervention, focusing on goal setting, not included as a procedure. While the and tracked over time; pacing up activities and individual advice data held within the database are •• Increase in length of follow-up to 12 on how to alter medication if the accessible to all clinicians, working with or 16 weeks. By merely extending the procedure is beneficial. Again, this Microsoft Access is not so familiar to current system, this is likely to have a service requires resourcing but would be many, so an automatic report generator negative impact on return rates; less complex to institute. has also been created in which a clinician •• Consider alternative modes of data In a very recent development, funding can enter their operator code to produce collection such as an online survey. has been secured locally to run a short- an individual summary, which can form a This would require significant term feasibility research project useful part of the appraisal changes to our current database and conducting more intensive screening pre- documentation. a secure server system, only interventional pain procedure and looking As with all ongoing data collection, accessible by patients with Internet at outcomes. This will aim to identify there is a compromise to be reached access and a level of information cohorts of patients who are more or less between gathering adequate useful data technology (IT) skills. Alternatives likely to be responders to interventions, to direct therapies at both individual and could include posting out a further and also those who are more or less service level versus a desire to use a form at a later follow-up date or likely to show a functional improvement number of large, well-validated telephone follow-up, both of which and will hopefully lead to a large-scale questionnaires to achieve the most would require personnel resources; prospective study further investigating scientifically robust results. Our service is •• Aim to improve our return rate by the findings. dependent on patients completing these using an SMS reminder service when forms themselves, at home, and the form is due to be returned. Conclusion remembering to post them back, then In the current financial straits of the NHS, clinicians entering data manually in order A further concern is that interventional it is vital to ensure we are delivering a to maintain the database. Any change to pain procedures should not be cost-effective Pain Management Service the nature or volume of data currently performed in isolation without addressing across all therapies, including collected needs to be carefully the wider principles of pain management. interventional pain procedures. As considered so as to continue to produce Setting realistic expectations with clinicians, we also have a responsibility to useful, meaningful data without patients for the role of interventional ‘first do no harm’, and should certainly increasing the non-response rate due to procedures prior to first procedure is not be exposing patients to potential risk complexity of questionnaire. vital. While the majority of patients will be (both physical and psychological) without Having presented the findings both encouraged to attend our patient good evidence of benefit. locally, and nationally, we have identified education sessions, and many are Our system of outcome assessment and a number of points in our current system referred on for specialist physiotherapy or associated database is an excellent which we would consider modifying to psychology, we do not have a system starting point to allow examination of our make improvements, as listed below: currently that allows for the timing of practices, and continues to grow with now these different interventions to be over 1,500 procedure entries. We look •• Modification to details recorded at optimised. If an interventional procedure forward to developing our system further to time of intervention to include gives a reduction in pain, this window of deliver a clear algorithm for interventional medications used, for example, to opportunity is an ideal time to work on pain procedures to our patients. allow for steroid versus non-steroid pain management through all resources. comparisons; This approach would require •• Modification to details recorded at co-ordination from all sectors within the Reference 1. Srivastava D, and Humble S. How do we follow up time of intervention to include note of pain management team but would our patients after injections? Pain News 2013; whether first time procedure or potentially be much more beneficial to 11(3): 182–4.
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End stuff Laughing the pain away Pain News 11(4) 265 –265 © The British Pain Society 2013 Shruthi Rayen King Edward VI High School for Girls, Birmingham [email protected]
When you bang your toe on the leg of a table, what do you do? Cry out in agony? Whimper and let tears of self-pity roll down your cheeks? Shout out a string of obscene vocabulary you hope your kids don’t hear? Or silently screw up your face and hop around in a spontaneous albeit strange dance? Whether you’re a hopper, a crier or sufferer in silence, some of you may be in a completely different and peculiar category altogether - the laughers. Those strange people who are in fits of hysterics when they’re in pain and you stand there not knowing whether to help them, laugh with them, or laugh at them. However, there may be some method to their hilarious madness. Research has shown that laughter generates the release of endorphins – the body’s own painkiller. It is thought that the long sequence of exhalations that goes hand save you from many heart problems in Laughter as a pain relief is not as in hand with genuine laughter contracts the future. relatively modern as you may think, and relaxes the abdominal muscles, Another form of this therapy is laughter because as far back as the 13th century, therefore triggering a release of yoga, or Hasya yoga, which was started doctors used humour as a diversion for endorphins. in 1995 by an Indian doctor named their patients to reduce pain. Even further The benefits don’t end there! A good Madan Kataria. However, this doesn’t back than that, in the Book of Proverbs, chuckle alleviates physical tension, involve your conventional downward- written over two thousand years ago, keeping your muscles relaxed for up to dogs and sun salutations. It uses states the healing influences of laughter. 45 minutes after. Similarly, it improves whimsical activities and conducted So, the next time you hit your thumb your immune system by lowering stress breathing exercises to generate laughter. with a hammer, don’t wake the hormones and increasing the production Moreover, doing this in a group would be neighborhood with your cries to deities of antibodies and immune cells. Laughter even more beneficial, because as we all and hurriedly rummage for a also protects the heart through the know, laughter is as contagious as the paracetamol, simply find humour in the increased blood flow, which advances common cold. So, turning a shy giggle situation and let those trusty endorphins the function of blood vessels; this can into a raging howl is far from impossible. do the rest of the work!
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Book review
Pain News 11(4) 266 © The British Pain Society 2013
Oxford American Pain Library: the equivalent doses of opioids is useful for Perioperative Pain Management prescriptions. There are additional sections by Richard D Urman, Nalini on assessment of pain and medication Vadivelu, OUP USA, ISBN 978-0- delivery systems. Several special 19-993721-9 populations such as paediatric, geriatric and obstetric patients, and patients with Reviewed by Dr Jayprakash Patil chronic pain and substance abuse are Locum Consultant Anaesthetist, identified and issues specific to these Manchester patient groups have been considered. Complementary and alternative medicines This slim pocketbook of just over a 100 are also briefly mentioned. The book ends pages deals with Perioperative Pain with a section on future directions and Management which is an important and outcomes. This final chapter highlights the highly relevant topic. As part of the increasing use of ultrasound in regional Oxford American Pain Library, it anaesthesia, the advent of newer invariably provides an US perspective on intravenous NSAID and local anaesthetic this issue with inherent differences in formulations, the use of anticonvulsants to practise to UK and Europe. This is also reduce postoperative opioid consumption reflected in the contributors’ list wherein and the potential application of biotoxins in the vast majority are American regional anaesthesia. practitioners. The book is referenced However there are a few omissions comprehensively. Given the topic dealt and errors of note. To mention a few, the with, it will always be a challenge to techniques of rectus sheath, subcostal collect all the required information but transversus abdominal plane blocks and yet keep the book size handy enough for high volume local anaesthetic infiltration Would I recommend this book?… As a quick reference. which is an integral part of current James Bryce, a British academic and The book begins with a chapter on a enhanced recovery programmes are not historian said, “The worth of a book is to team approach for the delivery of acute quoted. α-2 agonists such as clonidine be measured by what you can carry away pain services and provides an overview of and dexmedetomidine are also not from it”. A book of this type would be the mechanisms of pain with relevant mentioned. Agonism on sigma receptors useful as a quick reference guide for junior anatomy and pathophysiology. There are is erroneously attributed as a mechanism doctors and those “less specialised” in brief chapters on pharmacologic agents of action of opioids. A few colour allied surgical and medical teams. that are broadly classified as opioids and pictures and the use of a larger font However, I have doubts whether this will non-opioids and a rough guide to regional would make the book a lot easier on the appeal to readers who are specialised in anaesthetic techniques. The table listing eye of the reader. anaesthetics/ pain medicine.
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End stuff Course Review: Practical Pain News 11(4) 267 Management of Chronic © The British Pain Society 2013 Pain, Liverpool
Dr Sadiq Bhayani Advanced Pain Trainee, Nottingham City Hospital
Starting as an Advanced Pain Trainee not everyone is familiar with all the basic theatre staff, administration staff and can be a daunting task and there is a lot principles in pain, so their teaching is course dinner - all were brilliant with to take in. Given that we as trainees do tailored to the audience. opportunity to network and communicate not get that much exposure to Chronic There is section for joint outpatient further. Pain Medicine during our Core Training, clinics, which offered a great way to The content of the course was very Intermediate Training and Higher Training, know how multidisciplinary approach is well mapped for all levels of audience. I working as an Advanced Pain Trainee is useful for effective Pain Management of think the current structure and content of like starting as a Novice Trainee in chronic pain patients and also gave a the course is near perfect. If the course Anaesthetics. flavour of the day to day scenarios. The was over four days to cover all of the In order to get up to speed with the live theatre sessions were an absolute clinical stuff, that would put up the price knowledge, to develop the skills and hit; procedures were shown with all of and I am not sure whether everyone exposure to the various other aspects of the minute details, the importance of would like to go on a four day course. pain medicine like Physiotherapy, Pain patient positioning and adequate X ray I think this course is well worth every Management Programme, usage including projection of C-arm was penny of the small fee and is value for Neuromodulation, Psychology etc. there well worth knowing and observing in money considering just how much you is always a need for a comprehensive action. It would be useful to let the can learn in three days. The course also and affordable course which can pack all candidate know which clinic they have gives an opportunity to update your self the topics related to pain medicine, and been allocated to in advance; so they with what’s happening in the rest of the also give exposure to the other can read about it to get more out of that UK in terms of new therapies and disciplines as mentioned above. session. procedures etc., by allowing you to I recently heard about the “Liverpool The hands on skills on spine manikin network with various candidates from all Chronic Pain Management Course” and were very useful and we should not over the country. attended it, and discovered that it is just forget the excellent presentations from There wasn’t that huge a choice for what satisfies all of these needs. It’s a the faculty. Also, the grand rounds with vegetarians at lunch, so perhaps the great course. The Faculty are all very patients giving feedback were a great catering facilities can be improved. enthusiastic, friendly, knowledgeable and approach to put together everything that Overall, it’s an absolutely brilliant course very approachable. They also know that we had learned during the course. The and is strongly recommended.
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End stuff A question of mind over matter: Pain News 11(4) 268 –271 exploring the link between © The British Pain Society 2013 pain perception, duration and disability
Lucy O’ Connor Medical School Student, University of Manchester [email protected]
This essay was submitted for the Pain Relief Foundation’s Medical Student Essay Competition in 2012.
Chronic non-cancer pain is a severely patient. Several believe that, although Exaggerated pain perception increases debilitating and highly prevalent important, psychosocial factors alone do pain sensation in response to innocuous condition, responsible not only for the not fully explain the disconnect between or mildly painful stimuli with potentially persistent suffering of those afflicted, but pathology, pain perception and disability. severe clinical implications, including also soaring health-care costs, Indeed, altered pain processing is just magnified pain with physical activity, a unemployment and a growing burden of one part of the complex phenomenology major determinant of disability.5 Central social welfare.1,2 Our understanding of of chronic pain.5 This article will explore neuronal sensitisation is characterised by pain perception, and the complex the impact of the psychosocial amplification of the synaptic strength in mechanisms that regulate it, has dimension of pain on the chronicity of nociceptive circuits. This lowers the transformed in recent decades to symptoms and patient disability. threshold required to activate nociceptive embrace a biopsychosocial model, Importantly, it will pose the rather neurons, allowing signal generation by allowing increased credibility for the worrying question: does the way we innocuous stimuli. Importantly, both affective dimension of pain.1 This widely practise medicine today maintain, or these mechanisms are involved in the accepted model recognises that chronic even increase, disability? development and maintenance of pain is a unique and complex syndrome chronic pain.2 for each individual determined by The neurocognitive aspect of There are two independent, but physical pathology, health beliefs, coping pain parallel, pathways to the somatosensory strategies and social interactions.2,3 Pain is as diverse as man. One suffers cortices for processing afferent Importantly, it recognises that pathology, as one can. nociceptive sensation. The lateral pain perception and disability are -Victor Hugo, French poet and pathway comprises the cognitive aspect conceptually related, but distinct novelist6 of pain processing; this defines the entities.3,4 Growing evidence suggests Chronic non-cancer pain is associated location of pain and mediates the that psychosocial factors have such with altered mechanisms of central and experience of pain intensity. In contrast, profound influence on pain perception peripheral nociceptive processing, which the medial pathway constitutes the and disability that they deserve have profound effects on pain emotional processing of pain sensation, equivalent therapeutic attention to an perception. Increased pain sensation is which determines its effect on the identified pathological cause of pain.4 attributed to two phenomena: individual; this pathway carries affective Despite this, many clinicians associate exaggerated pain perception at higher signals to the limbic system.7–9 chronic pain with large discrepancies brain centres, due to disturbance of Importantly, nociceptive processing between the objective underlying endogenous pain modulation, and includes down-regulation of pain pathology and the subjective magnitude neuronal hyper-excitability.2,5 sensation. Automated control is of pain and disability experienced by the mediated through efferent inhibitory
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mechanisms in the periaqueductal grey ability to conduct other activities of daily inability to direct attention away from matter of the midbrain. Conscious living. Consequently, these techniques pain, which generates higher levels of control is modulated by activity in the are now considered counterproductive for pain intensity and psychological ‘pain control centre’ of the dorsolateral patients with chronic pain. Yet, evidence distress.18,19 The inability to redirect prefrontal cortex.8,10 suggests that patients frequently resort to attention from nociceptive sensations Discovery of the architecture of these similar maladaptive coping techniques, to may predispose individuals to chronic processing pathways prompted the minimise pain during physical activity. pain syndromes.8,15 development of mental strategies, using Unfortunately, repeated failure of these Catastrophising is also associated with focused attention and distraction, to ineffective strategies perpetuates distress, muscular reactivity and avoidance reduce pain sensation and improve inevitably resulting in cognitions of behaviour, both of which contribute to tolerance, by altering pain perception. catastrophising.15 perceived disability. In the long term, These strategies aimed to separate the catastrophising individuals avoid physical more subjective emotional aspect of pain activity, leading to the development of The power of pain perception perception from the more objective functional disability, associated mood components, intensity and location, by Fear is pain arising from the disturbance and depression.3,4,20 This focussing on these latter details.8,11–13 anticipation of evil. maladaptive cognition results in increased Distraction techniques seek to redirect -Aristotle, Greek philosopher6 use of health-care services and analgesic attention from a painful stimulus to a medication, and a reduced quality of simultaneous innocuous sensation, Chronic pain is difficult to define, as it life.19,21,22 The resulting fear of pain may through visual, audio or somatosensory cannot be distinguished from acute pain be more debilitating than the actual pain media.13 In contrast, focussed attention by duration alone but also by the body’s itself, as catastrophising is one of the encourages individuals to concentrate on inability to restore physiological functions most accurate predictors of physical a sensory component of the pain, for to normal homeostatic levels and the disability.4,18,23 Depression is another example, intensity or location.11 mere transient relief provided by major predictor of disability in patients Experimentally, these techniques medicinal treatment.1 Acute non-cancer with chronic pain, because it increases demonstrated great success in pain develops into chronic pain as a perceived pain sensation.18,24,25 modulating the perception of pain result of complex interactions between Worryingly, 50% of the 7.8 million Britons intensity.11,12 Clinically, however, the biological, psychological and social currently living with chronic pain are also results were disappointing, due to the factors.3,18 Growing evidence has diagnosed with depression.26 Interestingly, demanding nature of the techniques, highlighted the particular importance although pain duration and intensity which were too exhausting for patients to of psychosocial factors in this process. impact patients’ quality of life, it is more maintain long term.14,15 Overall, focussed Pain-related cognitions, health beliefs dependent upon their health beliefs.18,21 attention proved to be more effective and coping behaviours are key to than distraction, because it prompted determining a patient’s adjustment to Scepticism and the extinction patients to directly address the pain pain, which influences pain sensation of empathy sensation.12 Importantly, this and the development of disability.2,4,19 demonstrated the profound influence of Importantly, it appears that attentional The greatest mistake in the treatment individual attentional focus on the bias to painful stimuli is closely of diseases is that there are plasticity of somatic interpretation of associated with the development of physicians for the body and pain.16 chronic pain.17 There is a high prevalence physicians for the soul, although the The effort involved in these mental of these information-processing biases two cannot be separated. strategies was central to minimising the and maladaptive cognitions in patients -Plato, Classical Greek perception of pain.13,15,17 One theory with chronic pain, particularly philosopher17 suggests that the central nervous system catastrophising: an excessively negative has a limited capacity for information orientation towards painful stimuli and Individuals with chronic non-cancer pain processing; thus, mental strategies pain experience. Catastrophising creates often describe encounters with health- involving attentional focus compete for the perception that pain may be care professionals in which their pain is and consume more of the processing threatening, prompting the development met with doubt and disbelief, particularly resources, limiting those available for of pain-related fear. This fear affects in the absence of an obvious pathological nociceptive input. However, this leads to cognitive functions, promoting hyper- cause.27,28 For patients, the suggestion profound fatigue, reducing an individual’s vigilance for nociceptive input and an that their pain is purely psychosomatic, or
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even fictitious, is humiliating and biopsychosocial model of pain.31 The Pain pain sensation and associated distress, distressing. The insult to their dignity can Summit in 2011 advised the media of its by influencing pain behaviour. Ultimately, prompt the development of maladaptive moral obligation to improve awareness these programmes seek to improve pain coping techniques, including social that pain may be truly valid in the absence tolerance, mobility and function, allowing isolation, to avoid the embarrassment of of an objective pathological cause. patients to maintain a better quality of further judgements. Alarmingly, many Furthermore, it called for improved training life.2,3,34 There is now a strong evidence have described consciously altering their of health-care professionals, even going basis demonstrating better outcomes for behaviour and appearance in response to so far as to criticise the curriculum for chronic non-cancer pain with this disbelief, to visibly demonstrate the providing clinicians with less ‘pain training’ multidisciplinary treatment programmes credibility of their pain.27,29,30 Maladaptive than veterinary surgeons.26 Yet, there is involving physiotherapy, cognitive behaviour to legitimise an individual’s pain little evidence basis for the influence of behavioural and medical therapies, than is both physically and psychologically legitimising pain experience on a patient’s standard medical interventions.2,4,35–38 demanding, predisposing these patients pain behaviour, social interaction and Cognitive behavioural therapy, to further negative cognitions and psychological adjustment; it has only been providing patients with psychological and potentially generating functional noted in qualitative research studies.27,33 behavioural skills to confront their pain, is disability.27,29 However, early validation of symptoms is key to the success of these Unfortunately, stigmatisation of patients linked to the development of adaptive multidisciplinary programmes.34,38 with chronic non-cancer pain is common coping mechanisms, resulting in reduced Techniques of stress management, in the community, media and medical pain perception and greater long-term relaxation training, goal setting and practice, particularly in the absence of an functional ability.27 physical activity have demonstrated clear identifiable diagnostic cause.27,31 efficacy in adjusting patient Research nurses warn of an extinction of coping mechanisms.39 A empathy among clinicians, who base their central principle of behavioural judgement upon negative community therapy is that individuals are stereotypes, often perpetuated by the not helpless in managing their media.31 Stigmatisation is in part due to pain, but can overcome, or the assumption that symptoms are even avoid developing, directly linked to pathology, but also the significant functional barriers domination of Cartesian dualistic thinking through altered patterns of in Western medicine, which suggests that cognition.38 Cognitive pain must be the result of either a restructuring moderates the disturbed body or a disturbed mind.31,32 effect of persistent pain by Debates in Western medical literature that changing the way in which the explore chronic pain syndromes in the brain processes nociceptive absence of identifiable organic pathology information, in a similar manner to the Multidisciplinary management often conclude that the pain must be modification of juvenile brain processing of pain ‘psychogenic’, precluding further in early life.1,19 Early intervention can meaningful observations or We must build dikes of courage to reduce the pain sensation, improving communication with the patient. This hold back the flood of fear. tolerance of chronic pain and minimising scepticism can cause iatrogenic -Martin Luther King Junior, leader disability. More significantly, it could even stigmatisation.31 in the African American Civil Rights prevent the development of chronic Change in community and clinical Movement. pain.4,19,40 attitudes will require education Medical pharmacotherapy for chronic The skills and experience of health- programmes to raise awareness that pain remains a challenging balance care professionals are fundamental to the psychosocial factors can profoundly between providing adequate pain relief success of cognitive behavioural therapy, influence and worsen an individual’s and tolerability of medication. Yet, it can but outcomes are principally dependent experience of pain. Increased only provide transient pain relief.1,2 The upon the comprehensive nature of the consciousness of this fact among health- biopsychosocial model heralded programme and methods of intervention. care professionals may trigger research development of multidisciplinary Patient characteristics and programme re-emergence of lost empathy and a programmes for the management of duration can influence efficacy; renewed understanding of the chronic pain, which aimed to minimise successful outcomes require effortful
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commitment of participants to engage productivity in the United Kingdom, and models for adaptive coping behaviours.26 with the problem.17,38 Studies have is regarded as a considerable barrier to Although costly, better training of health- shown that highly distressed patients, seeking employment. This prompted the care professionals is essential, and with more negative cognitions and nation’s first Pain Summit in 2011. should incorporate skills in eliciting evidence of catastrophising, achieve Among many issues, this meeting psychosocial factors and characteristic poorer outcomes. However, it is highlighted the disparity in health-care behaviours in chronic pain. Combined important to note that even minor provision for chronic pain across the with the expansion of multidisciplinary cognitive changes in this patient group country, and repeatedly acknowledged programmes across the United Kingdom, could substantially improve their quality the potential economic benefits of this would elevate primary care providers of life.34 improved pain management to ‘keep to a uniquely powerful position in which Chronic pain is not a homogenous people in work’. This, it was claimed, to identify and target psychosocial entity, and the variables of the could improve self-esteem and provide factors early in the disease process, biopsychosocial model are financial independence, but perhaps before pain has become chronic.4,26 interdependent; thus, one cannot be most cynically, would boost British treated at the expense of another. productivity ‘by several billions of Conclusion Effective rehabilitation requires detailed pounds’.26 The patient’s pain perception has the assessment of all the dimensions of Notwithstanding the dramatic effects potential to influence not only the chronic pain and must include advice of cognitive behavioural therapy, current duration and severity of their pain but and support to manage patient multidisciplinary programmes continue to also their mobility and daily function. It is expectations.4 Importantly, produce disappointingly high rates of essential to appreciate the complex multidisciplinary programmes have also therapeutic failure, with evidence of interaction between psychosocial factors proved the most cost-effective approach short-term effects and uncertainty and physical pathology, and their to managing chronic pain.3,18 However, it surrounding the factors most crucial to influence on the development of patient is essential to remember that, for many, symptoms. This is particularly true chronic pain is caused by a permanent of chronic pain, where pathological disease process. As such, catastrophising and inability to their pain and functionality may remain redirect attention from painful relatively unchanged by cognitive stimuli substantially increase a behavioural therapy.39 patient’s risk of prolonged pain and disability. Thus, it is imperative that The current state of play early and effective cognitive behavioural therapy is available to Ideas not coupled with action never all patients suffering severe or become bigger than the brain cells acute pain. Medical consults have they occupied. a powerful effect on pain -Arnold Glasgow, American satirist6 perception and legitimisation, which can be unfortunately Despite convincing evidence, national patient improvement.2 More effective compromised by iatrogenic audit statistics reveal a relative paucity of programmes are comprehensively stigmatisation. Current service provision multidisciplinary programmes in the multidisciplinary and integrated into in the United Kingdom is woefully United Kingdom, with only 64% of pain primary care services. There is a inadequate, but expansion and clinics providing multidisciplinary desperate need for better primary care continued development of intervention in 2011. Even more tools and training, to identify and manage multidisciplinary pain management worryingly, only 40% of these could psychosocial risk factors, and education programmes would help not only those provide evidence to support their claim.26 to address iatrogenic stigmatisation of affected by the pain but potentially the Yet, it is a truth universally acknowledged patients, in both clinical and community nation’s economy. In a time of such that chronic non-cancer pain places a environments, and discourage the economic uncertainty, these interventions collective burden on society and dualistic framework that perpetuates cannot be ignored. represents a major challenge for public negative stereotypes.4,31 The media health.26,41 It continues to feature among should be central to communicating this References not included but can be the top 10 health problems limiting message, and promoting positive role obtained from the author by email.
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End stuff Remifentanil PCA in Pain News 11(4) 272 acute sickle crisis pain © The British Pain Society 2013
Dr Arif Hasan, ST6 Anaesthetics and Dr Robeena Akhtar, Consultant Anaesthetist University Hospital of North Staffordshire, Stoke-on-Trent [email protected]
Case report to 6 with morphine) but was pleased with Remifentanil 31 year old pregnant patient with known the pain relief, which she stated was A μ-opioid agonist, remifentanil is rapidly sickle cell disease was admitted through superior to morphine but short lasting. broken down by non-specific plasma A&E with severe leg pain and shoulder She was also happy about the fetal and tissue esterases resulting in a short pain. She was 38 weeks pregnant and movements she could feel as she didn’t elimination half life (3-10 minutes). It is booked for an elective LSCS in the feel it more last time and was worried. context insensitive, in that the half life, following week. She was treated with After the acute pain episode was over, clearance and distribution are fluids and analgesia (morphine boluses). she was transferred back to the ward independent of duration and strength of She was transferred to HDU in the with oral analgesia. Later she had a infusion. A comparison of APGAR scores maternity unit. Anaesthetist was asked to LSCS uneventfully. of consecutive neonates born by normal prescribe morphine PCA (which the At the postoperative visit, patient was vaginal delivery to women receiving no patient used to have before in her acute satisfied with remifentanil PCA and analgesia, with those born to women crisis). The patient was worried that at requested that she should be given if a using remifentanil PCA, demonstrated no her last delivery, the baby was a bit similar episode occurs again. difference. Thinking on the same lines, floppy as she had a similar episode and using remifentanil in acute sickle pain had morphine PCA. crisis resulted in good analgesia as well Discussion as patient satisfaction. Sickle Cell Disease Management Autosomal recessive genetic blood References We discussed with the patient regarding disorder characterised by red blood cells Patient-controlled analgesia for labour using remifentanil instead of morphine PCA - that assume an abnormal, rigid, sickle remifentanil: a feasibility study Br J Anaesth 2001; 87:415–20 short acting as well as minimal residual shape. Sickling decreases the cells Remifentanil patient-controlled analgesia for labour: a effects to the fetus. Patient agreed and flexibility and results in a risk of various complete audit cycle. Buehner U, Broadbent JR, was educated about the usage of complications. The sickling occurs and Chesterfield B. Source - Department of Anaesthetics, Rotorua Hospital, remifentanil PCA. Patient used it because of a mutation in the hemoglobin Rotorua, New Zealand. erratically (pain score of 8 as compared gene. Remifentanil PCA in acute sickle cell bone pain Erratum
Pain News sincerely apologises for the typo error in the second paragraph of page 143 of our September issue; it should read “Chronic Pain Services across Glasgow”.
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Pain News 11(4) 273 © The British Pain Society 2013
New Members
Ratified at the September 2013 Council Meeting
Name Position Institution Dr Kate Bellingham GP Partner, GPWSI in Chronic Pain Page Hill Medical Centre, Sheffield Dr Simon Berrisford GP Eric Moore Partnership Mrs Amanda Buckley Specialist Physiotherapist in Back Pain Back Pain Unit, King’s Mill Hospital Miss Charlotte Anna Cochrane Student Psychologist Gloucestershire Hospitals NHS Foundation Trust Miss Maxine Louise Cozens Specialist Occupational Therapist Defence Medical Rehabilitation Centre Headley Court Dr Lene Forrester Principal Clinical Psychologist Aberdeen Royal Infirmary Prof. Neil Edward Fowler Professor & Head of Exercise and Sports Manchester Metropolitan University Science Ms Sarah Jane Kelly Specialist Occupational Therapist King’s Mill Hospital Dr Giandomenico Lannetti Reader in Human Neuroscience University College London Dr Julian Scott-Warren ST6 Pain Medicine/Anaesthetics Pennine Acute Hospitals NHS Trust Miss Madeleine Smith Deputy Clinical Nurse Specialist St Thomas’ Hospital Mrs Georgina Stickley Clinical Specialist Physiotherapist in Pain Birmingham East & North PCT Management Dr Karla Toye Clinical Psychologist Manchester and Salford Pain Centre Dr Mohan Kumar Vellalapalayam Sathyamoorthy Specialty Registrar Princess Royal Hospital, Telford Dr Sarah Louise Woods Principal Clinical Psychologist Wansbeck Hospital
December 2013 Vol 11 No 4 l Pain News 273
PAN510832.indd 273 12/11/2013 12:23:09 PM Now accepting primary research papers
Official journal of the British Pain Society The Journal aims to broaden its scope and become a forum for publishing primary research together with brief reports related to pain and pain interventions. Submissions from all over the world have been published and are welcome.
Good reasons to publish in British Journal of Pain… • Published by SAGE since 2012, the journal is now fully online and continues to be published in print. Browse full text online at bjp.sagepub.com • Official journal of the British Pain Society, the journal is peer reviewed, with an international multidisciplinary editorial board • Submit online and track your article on SAGEtrack • High visibility of your paper: the journal is currently free to access and is always free to link to from cited and citing references on HighWire Press, the world’s leading e-content provider www.britishpainsociety.org
Now accepting original research and review papers in these areas: Adjuvant therapies for acute and chronic pain Pain management in the adolescent/young adult Basic science Peripheral regional analgesia Commissioning Pharmacogenomics Local anaesthetics Primary care management Mobile technologies Psychology of pain Neuraxial analgesia for acute pain Service re-design Neuropathic pain Sleep and pain NSAIDs and COX-2 inhibitors Therapies including lifestyle orientated treatments Opioids Transition between acute and persistent pain Pain management in palliative and end of life care Pain management in patients with HIV
For enquiries about your paper contact [email protected] Submit your paper online on SAGEtrack: http://mc.manuscriptcentral.com/bjpain
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